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Full text of "Harvard medical alumni bulletin"

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Harvey 
1 895, has been hailed as the 
father of modern neurosurgery 
and one of the giants of twen- 
tieth-century medicine for his 
contributions as a surgeon, 
teacher, and researcher. 



W I N M R : 5 • \ O L U M E 7 6, NUMBER 3 



rONTF.NTS 




DEPARTMENTS 



Letters 3 

Pulse 6 

Virtual learning in the elassroom, 
teaching the teachers, the molecular 
structure initiative, medical caricatures 

President's Report 9 

hyWitdKllTRiibkin 

Bookmark 10 

A re\'iew by Elissa Ely of An Arrow 
Through the Heart: One Woman's Story 
of Life. Lo\'e. and Suryiving a Near Fatal 
Heart Attack 

Bookshelf 11 

Benchmarks 12 

Ne\\' \ocal cord surgeries can keep 
people from changing their tune. 

Alumnus Profile 52 

HMS has graduated many family 
dynasties, but only one with ten 
alumni in just two generations. 

Class Notes 54 

InMemoriam 58 

John Gordon Scanncll 

In Memoriam 58 

JohnT.EdsaU 

Obituaries 60 

Cover mage courtesy of The British Library (Arundel 295, 




SPECIAL REPORT: THE ART OF TOUCH IN HEALING 



The Art of Touch in Healing 14 

Physicians were once offended by the idea of a stethoscope intruding 
between their patients and themselves; now they want the distance 
increased. 

Different Strokes 16 

From neurobiology to surgery to family medicine, science is 
transforming applications of touch. 

bv BEVERLY B A L L A R O 

An Intangible Art 28 

A physician reflects on the centraUty of touch in making patients 
better — and in making better doctors. 

/) V M I C H A E L A . L A C O M B E 

Sleight of Hand 32 

An internist scrutinizes patients' hands to uncover clues to their 
physicLiI and emotional well being. 

i) V S U S A N N A BEDELL 

The Machine and 1 36 

His ovk'n experience with radiation treatment for cancer leads a physician 
to reflect on the intersection of flesh, spirit, and steel. 

h\ RAY B A B I N E A U 

Sparrin' Partners 42 

when Sparr's Drug Store closed its 
doors after nearly IQ years of serving the 
HMS community, it marked the passing 
of a storied institutional relationship. 

by BEVERLY BALLARO ^^F ^"^ 

The Reluctant Physician 46 /X 

A Boston blue blood with dreams of 

trading his stethoscope for a farmer's ; ^ 

plow finds he can t turn his back on ' ^^ . 

a community in need. - -y^ 

bv STERLING HA YNES / _i/^ ^ 

Folio 256) ^ V# *I0I I ^l 




Harvarr] M edimi 



ALUMNI BULLETIN 




In This Issue 

LL OF THE Fr\T; SENSES HAXT DIAGNOSTIC POTENTIAL IN MEDICINE, AND ALL 

wi ^H five have been at least partly augmented or replaced by technological 
proxies. Two of the senses, taste and smeU, are essentially obsolete in 
diagnosis — even when one grants that taking a good whiff of an uncon- 
scious patient is always worthwhile. But neither smell nor taste could ever pro\'ide 
information as specific as a stat chemistry result. I doubt whether the most staunch- 
ly traditional physician feels that his or her identity has been substantially eroded by 
a clinical laboratory, and medical information arriNing in cither the olfactory or gus- 
tatory modality is quite likely to pro\'oke the reflex of disgust. 

Hearing, by contrast, remains central to both the reality and the symbolism of 
the physician's diagnostic role. The stethoscope instantly identifies a cartoon doc- 
tor, and there is much about the dexice that can be used to advertise one's rank, 
role, and seriousness in the profession; color (pastel tubing means lower status); 
location (draped around the neck means busy and very serious); construction 
(multiple bells and diaphragms means extra competent). Nevertheless, as someone 
who always had to struggle to get the ear pieces firmly sealed and then could not 
reliably distinguish between "Kentucky" and "Tennessee," I would ha\e happUy 
sacrificed that bit of status for an easHy ordered echocardiogram. 

Vision seems to me the least fraught of the diagnostic senses. What the clinician 
garners from looking at the body's outer surface remains as valuable as ever, and 
imaging technology developed in the last hundred years has wonderfully extended 
our optic reach. Few but the most nervous will, I think, worry that technology is 
leading to an era when patients will be led to a room full of imaging devices while 
the physician remains in another room connected only by high-speed data lines. 

Touch is, in many ways, the most morally comphcated of the senses because it is 
never a merely sensory activity; it is action as well. We touch patients for diagnostic 
information, but privileged touch carries disturbing implications of authority, 
aggression, coercion, and eroticism, as well as reassurance, nurturance, protection, 
and affection. This issue of the Bulktin explores aspects of touch as a diagnostic and 
healing act in medicine. 



***** 



Gordon Scannell '40, editor of the Bulletin from 1981 to 1994, died last August. In 
this issue George Richardson '46, Gordon's predecessor as editor, remembers Gor- 
don and his life. Gordon brought a gentle and generous personality to his role as 
editor of the Bulletin as he did to so many of his other pursuits. He was learned but 
wore his learning lightly. His interests were wide ranging, and his humor droll. 
His was a graceful stewardship of the Bullctm. and he was warm and supporti\'e 
to his successor. We miss him and are grateful for his guidance. 



^,U^ 



Am.[ [f\A 




EDITOR-IN-CHIEF 

William Ira Bennett '68 

EDITOR 

Paula Brewer B)Ton 

ASSOCIATE EDITOR 

Beverly Ballaro. PhD 

ASSISTANT EDITOR 

Su.san Cassidy 

BOOK REVIEW EDITOR 



Elissa Ely ' 



EDITORIAL BOARD 

JudyAnn Bigby '78 
Rafael Campo '92 

Elissa Ely '88 

Atul Gawande '94 

Robert M. Goldwyn '56 

Petri Klass '86 

Xictoria McE\oy '75 

James J. O'Connell '82 

Nancy E. Oriol '79 

Eleanor Shore '55 



DESIGN DIRECTOR 

Laura McFadden 



ASSOCIATION OFFICERS 

Mitchell T Rabkin '55, president 

E\'e J. Higginbotham '79, president elect 1 

Joseph K. Hurd, Jr. '64, president elect 2 

Paula A. Johnson "85, vice president 

PhyUis L Gardner '76, secretary 

Cecil H. Coggins '58, treasurer 

COUNCILLORS 

Nancy C. Andrews '87 

Rafael Campo '92 
Donnella S. Green '99 
Barbara J. McNeil '66 
Laurence J. Ronan'87 
Mark L. Rosenberg '72 

Kenneth I. Shine '61 

Francis C. Wood, Jr. '54 

Kathryn A. Zufall- Larson '75 

DIRECTOR OF ALUMNI RELATIONS 

Daniel D. Federman '53 

ASSISTANT DEAN FOR ALUMNI 
AFFAIRS AND SPECIAL PROJECTS 

Nora N. Nercessian, PhD 

REPRESENTATIVE TO THE 
HARVARD ALUMNI ASSOCIATION 



Joseph K. Hurd '64 



The Harvard Medical Alumni Bulktm is 

published quarterly at 25 Shattuck Street. 

Boston, M.A 02115 ' by the Harvard 

Medical .-Mumni .Association. 

Phone: (617) 384-8900 « Fax: (617) 384 8901 

Email: bulletin@hms.harvard.edu 

Third class postage paid at Boston. 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street. Boston. MA 02115 

ISSX 0191 7757 • Pnnted m the U.S.A. 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



SECOND OPINIONS FROM OUR READERS 



T.ETTERS 






Crimson Pride 

I just read your 75th anniversary issue. 
It's so wonderful! You make me proud to 
be connected with HMS. 

LESTON HAVENS, MD 
CAMBRIDGE, MASSACHUSETTS 



High Interest Rating 



Your 75th anniversary issue was won- 
derful. 0\er the years, at social gather 
ings, hospital cafeterias, committee 
meetings, and boardrooms, I've often 
found doctors as a group — no matter 
how competent or even brilliant — to be 
a dull bunch. Discussions ot politics, 
books, aesthetics, and values that were 
lively in a mixed gathering have turned 
leaden when conducted among doctors 
only. The Bulletin regularly refutes all 
that, however, and the 75th anni\'crsary 
issue finally proved that I've just been 
talking to the wrong people. 

We can be proud that, apart from med- 
icine, HMS graduates are pretty interest- 
ing people after all. Ne\'ertheless, 1 think 
we could be even more interesting — and 
possibly more humane — if the admis- 
sions process took seriously the famous 
suggestion by a distinguished HMS 
alumnus, the late Lewis Thomas '37, that 
medical schools not consider anyone who 
majored in science in college. 

JAMES S. BERNSTEIN '52 
ROCKVILLE CENTRE, NEW YORK 

Worth the Wait 

A lew da)'s ago in a Newton doctor's 
waiting room, I picked up the summer 
issue of the Bulletin, \cnerable indeed! 
Mrs. Monahon and I arc not doctors but 
neither of us could put it down until we 
had read it, with great joy and enlighten- 
ment, from cover to co\cr. 

ROBERT MONAHON, SR. 
PARSONSFIELn, MAINE 



All Shook Up 



Great issue! You and your staff arc tcrrif 
ic writers and editors. Perfect for the old 
stodgy school. 

ANTHONY PATTON '58 
DANVERS, MASSACHUSETTS 





PRESSED TO KILL 

OUR 75 IH ANNIVERSARY ISSUE STIRRED UP MANY MEMORIES. THE 

clinical encounters described in "The Art Is Long" in particu 
lar reminded me of one of my own experiences. It took place 
around I960, at a time when I was just getting settled into my 
practice. A man had been referred to me with an acute inflam- 
mation of the gall bladder, which I remo\'ed. He recovered, and on his very 
last visit to my office in Brooklinc, he held out his hand, thanked me, and 
said, "I see that Blue Shield paid you S3 50 for my operation. Plea.se let me 
know what more I owe you. I'm pleased w ith the good job you did, and I 
want to settle my account." 

"I accept Blue Shield payments," I replied, "and there's nothing more 
you owe me. Thanks for your offer, but we're settled in full." 

"That's nuts!" he said. "You saved my life, and all you get is 350 bucks? 
I don't understand it, but if that's the way you do business, okay." 

He left the office but returned almost immediately. After closing the 
door, he looked me square in the face and said in a low voice, "I ha\'e a spe- 
cial business, and perhaps I can repay you in that way. Is anybody bother- 
ing you? Is anybody on your back? What I mean to say is, would you like 
anybody rubbed out?" 

With a short gasp, I managed to get out, "No, no thank you!" 

Before I could say anything more, he added, "How about your wife?" 
Mouth agape, I shook my head. 

"Okay, then. I appreciate what you did, and I just wondered if you might 
need my help." He held out his hand, I did the same, we shook hands, then 
he turned and left. I never saw him again. I can't remember his name now, 
but I've thought of him more than once, though I've never wished him to 
come back to do a job for me. 

JOHN L. ROWBOTHAM '46 
FRANCONIA, NEW HAMPSHIRE 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



^ T.ETTKRS 



SECOND OPINIONS FROM OUR READERS 




A Touch of Class 

what a great issue, all the way through! 
You truly captured and set forth with clar- 
ity the history of the past 75 years at HMS. 
The older I've grown, the more impor- 
tant the Bulletin has become. I was most 
impressed with the amount of material 
you covered in the 75th anniversary issue 
and how well you attached it to the 
nation at the time. Any of us who were 
extant throughout the period cannot 
help but see how well you co\'ered the 
years. Many thanks for bringing us all 
up-to-date as well as taking us for a good 
ride backward. 

HENRY H. WORK '3/ 
BETHESDA, MARYLAND 

Keeping the Faith 

I enjoyed the contents, the incisive wit 
and wisdom, the illustrations, the vin- 
tage advertisements, the quizzes, and the 
innovative organization of the 75th 
anniversary edition. The play on words in 
the cover title — "making house calls for 
75 years" — was a nice touch, because the 
Bulletin's visits are very welcome and 
much appreciated. 

I would like to offer an inspirational 
prayer that seems to resonate with the 
lives of the great physicians who were 



honored in this edition. The prayer — by 
Sir Robert Hutchinson, a renowned 
physician and teacher — has been a bea 
con of hope and source of strength for me: 

"From an inability to let alone; from 
too much zeal for the new and contempt 
for what is old; from putting knowledge 
before wisdom, and science before art 
and cle\'erness before common sense; from 
treating patients as cases; and from mak- 
ing the cure of the diseases more grievous 
than the endurance of the same. Good 
Lord deliver us." 

Hats off to all those who made this 
issue possible and deep appreciation for 
the satisfying experience of reading it. 

VELANDY MANOHAR, MD 
HADDAM, CONNECTICUT 

Training Daze 

I enjoyed the letter of John Cadigan "53 
in the Summer 2002 issue about the 
military scene at HMS during World 
War II. In the interest of historical accu 
racy, however, I feel it necessary to make 
a small correction. 

The first commanding officer of the 
Army Specialized Training Program unit 
at HMS was Captain Russell Fairbanks, 
an artillery officer and product of the Har 
\'ard ROTC program. To put it mildly, his 
efforts to convert \ anderbilt Hall to West 



Point on the Circle of Tugo were not 
always appreciated by the student-sol- 
diers. It was he, and not Major Jerome 
Rosengard, who exhorted the troops at a 
morning formation to "make this the best 
damned medical school in Boston." Some 
one in his audience had a friend on the 
staff of the New Yorker, and Fairbanks s plea 
was subsequently published in "Talk of 
the Town." Its pubUcation did not con- 
tribute to furthering a warm and fuzzy 
relationship between Captain Fairbanks 
and the students. A direct approach to the 
War Department by Har\ard administra- 
tors e\entually resulted in his transfer. 

Captain Fairbanks was replaced by 
Major Rosengard, a large, jo\ial obstetri- 
cian from the Chicago area, who came to 
HMS from a tour of dut}' in Iceland. 
Rosengard remained in command for the 
duration and was uni\'ersally belo\'ed. As 
an indication of his popularit}', the plot of 
the December 1943 Aesculapian Club 
show had the Harvard Unit serving with 
him in Iceland. (The hit song was "The 
Fur-lined Jockstrap WiU Save the Day") 

Admittedly, my comments are sec- 
ondhand; I arrived at HMS in January 
1944 and, moreo\'er, was in the Na\'y 
V-12 unit. The facts, however, are 
vouched for, as recently as this morning, 
by my brother, Louis Selverstone '44, 
who lived through it all. 

NORMAN J. SELVERSTONE '47 
CAMBRIDGE, MASSACHUSETTS 

Rise and Fall 

Recent Bulletin articles detailing the 
experiences of HMS alumni who ser\'ed 
in World War II ha\'e reminded me of my 
own wartime encounter with one of 
medicine's most enigmatic figures. 

Ferdinand Sauerbruch was, in the years 
following World War I, probably the most 
famous surgeon in Europe. He had devel- 
oped a procedure to make skin tunnels 
under the flexor and extensor muscle 
groups of the forearm in patients who had 
undergone amputation of the hand. 
Wooden pegs placed through the healed 
skin tunnels were attached to wires, 
which in turn were attached to a pros- 
thetic hand. The flexion and extension of 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



the arm muscles would produce move 
ment of the pegs, which would open and 
close the fingers of the prosthesis, which 
became known as "the Saucrbruch hand." 

In 1933, Saucrbruch welcomed Hitler's 
assumption of power. Over time, he oper 
ated on many important Nazi officials, 
including Joseph Goebbels and President 
\'on Hindcnburg. But eventually he grew 
disillusioned with Hitler, confiding to 
friends his opinion that the Fiihrer was 
"unquestionably out of his mind." 

Following the \\'ar, Saucrbruch under- 
went the de- Nazification process by the 
Allied powers and was reinstalled as chief 
surgeon of the Charite\ the largest hospi- 
tal in Berlin. By 1946, Saucrbruch was 
back in business. That same year, I was 
assigned as a chief of anesthesia at the 
U.S. Army 279th Station hospital in 
Berlin. One morning the commanding 
officer of the Charite arranged for mem- 
bers of my hospital's surgical staff to 
attend a clinic presented by Saucrbruch. 

Our group was led to a large surgical 
suite with three operating tables. On the 
central table lay a woman with a large goi- 
ter, which Saucrbruch planned to remo\'e 
using local anesthesia. After about 15 min- 
utes of waiting, a hush fell over the room. 
My interpreter whispered, "He is com 
ing!" Saucrbruch entered, trailed by a 
large retinue of doctors and nurses. He 
had apparently already scrubbed and 



went directly to the table, where he put 
on his gown and a pair of thin cotton 
gloves, explaining to us as he did so that 
rubber glo\'es were unavailable. 

He proceeded to make a long "collar" 
incision across the patient's neck. He then 
dissected the skin flaps by inserting one 
hand under the slightly dissected upper 
flap and the other hand under the edge of 
the lower flap. He pulled on these with 
great force, raising both flaps about two 
inches. At that moment, the patient 
shrieked in obvious pain. 

Saucrbruch reprimanded her in a 
harsh tone, after which the patient did 
not utter another sound. "What did he 
say to her?" I whispered to the inter 
preter. "He said," the interpreter relayed, 
"'Hush, woman! Don't you know that this 
is Saucrbruch operating on you?'" 

After a few minutes, Sauerbruch's cot 
ton gloves became saturated with blood. 
Muttering an oath, he stripped them off 
and finished the operation barehanded. 
The huge goiter involved both lobes of 
the thyroid, but he had it out after about 
20 minutes, then turned the rest of the 
operation over to his assistants. 

Saucrbruch then turned his attention 
to the next patient — a veteran whose 
old wound had developed a femoral 
arteriovenous fistula. He ligated the 
artery and vein and all their branches, 
working meticulously for about an hour. 



As soon as he finished that operation, 
Saucrbruch moved to the third patient — 
a war amputee — constructing skin tun- 
nels for the eventual fitting of a "Saucr- 
bruch hand." Following this virtuoso 
performance, we were escorted to an 
amphitheater where Saucrbruch had 
assembled a group of his former patients, 
all of whom displayed spectacular surgi- 
cal results. Saucrbruch then made a pica 
for help from the Americans, as his hospi 
tal lacked many of the bare medical 
necessities. Unfortunately, we were all 
restricted by an order of "no fraterniza- 
tion" with the Germans. 

Sadly, just a year after this encounter, 
Saucrbruch began showing signs of 
dementia, to the point that he became a 
dangerous surgeon. Yet the esteem in 
which the German people held him 
enabled him to continue operating for 
another three years. 

Saucrbruch died in 1951 and was 
buried wearing a surgical gown with a 
stethoscope clasped in his hands. 

ROBERT MCBURNEY '43B 
MEMPHIS, TENNESSEE 

The Bulletin welcomes letters to the editor. 
Please send letters by mail (Har\'ard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (6J7-384-890J); or 
email (bullctin&>hms. harvard.edu). Letters may 
he edited jor length or clarity. 




LARGER THAN LIFE 

IMAUINh MY ASrONISHMENT AND DELIGHT AT OPENING MY COPY OF THE BULLETIN 

(which r\'e been receiving with pleasure ever since my father returned for his sec- 
ond tenure as editor in 1967) and finding my father, Joseph Garland '19, there — full 
lace, full page — about to deliver one of his "whimsiciil understatements." 

As the wheel happens to turn, I recently dehx'cred the annual Garland Lecture at 
the Boston Medical Library, on the subject "The Global Reach of a Gloucester Boy: 
joe Garland and the New England Journal of Medicine, 1922-1967" — a period that also 
spanned his two tenures with the Bulletin, which gets better by the issue, and editor. 

JOSEPH E. GARLAND 
GLOUCESTER, MASSACHUSETTS 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



ptit.se 



I MAKING THE ROUNDS AT HMS 



The Educational Virtue of Virtual Education 




ACROSS THE BOARD: Anjelica Garza '06 makes use of a high-definition plasma 
screen, a new tool in the era of technology-based learning. 




COMBINATION OF DAZZLING 

hardware and seamless soft- 
ware is transforming tfie 
educational experience for 
HMS students — and turning the 
MyCourses Web platform into a \irtual 
nexus of teaching and learning. 

Recently installed into each of the 27 
tutorial rooms in the Tosteson Medical 
Education Center are 50 inch, high 
definition plasma display screens along 
with wireless keyboards and mice. To 
complement the new hardware, "We've 
added new software to MyCourses 
that Wcbenables the entire tutorial 
process," says John Halamka, chief 
information officer at HMS and associ 
ate professor of medicine at Beth Israel 
Deaconess Medical Center. "MyCours 
es empowers tutorial faculty to share 
multimedia resources with students in 
a way that fosters student and faculty 
interaction. Additionally, faculty can 
use MyCourses to evaluate student 
tutorial performance, run forums to 



clarify and reinforce the knowledge 
gained in tutorials, and exchange email 
with their students." 

Although the School's Web based 
educational resources have steadily 
expanded in scope and quality, until 
recently their application has been lim 
ited largely to individual use by stu- 
dents outside the classroom. The new 
technology allows students to access 
this wealth of material in the eight-stu- 
dent tutorials and other group settings. 

"Now we arc not only using My- 
Courses as a supplement to classroom 
learning, but it has actually become 
part of classroom learning," Halamka 
says. "We're able, for example, to bring 
up microscopy slides, videos of patients 
describing their own diseases, or the 
latest literature from the New England 
journal of Medicine. MyCourses has 
become the way \^'e dcli\'er knowledge 
both inside and outside the classroom." 
The site is now accessed more than 
40,000 times a day. 



Amy DiAdamo, a course manager for 
Year 1 cour,ses, says the system's designers 
were careful to preserve the .sense of 
community and confidentiality that 
characterizes the tutorial environment. 
"Once the tutorial group comes into the 
room, it's all about the students and their 
relationship with the tutor, and we 
mimic that with MyCourses," she says. 
No one but the tutor and students can 
access a tutorial group's private page, 
which opens with the names and photos 
of each "roup member. Recognizing that 
each tutorial has unique needs and teach 
ing methods, the system's developers also 
built in flexibility. For example, tutors 
can control the timing of when students 
sec each section of content and add any 
.supplemental material they choose. 

In addition to the tutorial room hard- 
ware, recent enhancements to My- 
Courses include; Search, a function that 
can search every resource, event, and 
announcement in MyCourses by key- 
word; MyStorage, a feature that enables 
students and faculty to upload and 
retrieve files via the Web from anywhere 
in the world and provides a 50-megabyte, 
secure personal storage area; MyWeb, 
which allows students to upload and 
manage personal Web pages; Link Man 
ager, which makes managing HMS and 
personal links on MyCourses easier; and 
Document Writer, a Web based version 
of Microsoft Word that allows students 
and faculty to write complex documents 
without needing any software outside 
their Internet Explorer Web browser. 

"Improving and updating our tutorial 
system is a key element of the curricu 
lum reform we are now undertaking at 
Har\'ard Medical School," says HMS 
Dean Joseph Martin. "The evolution of 
MyCourses as both an indi\'idual and a 
group teaching tool is a wonderful 
example of how technology can help us 
achieve this goal." ■ 

Tom Rcvnolds is a writer in (he dean's office at 
Harvard Medical School. 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



Reaching Out to Teachers 




OURTEEN'YEAR OLD "TINA" WAS 

a fictional patient in teacher 
Heather Cabreras science 
class last fall at New Mission 
High School in Roxbury. But Tina, whose 
breathing troubles began with asthma 
and ended with pneumonia, offered real 
life lessons. One day, when Cabrera's 
seniors were learning how to take their 
respiratory rates, they discovered they had 
worse numbers than Tina on her sickest 
days. "More than half of my kids ha\'e asth 
ma," says Cabrera, a participant in the 
HMS Teachers Institute. "Roxbury has 
one of the highest asthma rates in Boston." 
Roxbury also has a high percentage 
of undcrreprcsented minorities, whose 
increased presence in the sciences is part of 
the mission of the Teachers Institute. 
Almost 100 teachers from local schools 
ha\'e attended three da\' mini- sabbaticals 
since the program began in 1994 with 
funding from the Howard Hughes Medical 



Institute. The teachers return to school 
with a tool kit of ideas and equipment. 

The Teachers Institute has become an 
important part of helping to keep Boston 
science teachers up to-date in the fast 
mo\ing sciences, says science teacher John 
DioDato. "That's what's so special about 
what's going on between Boston and 
HMS now," DioDato says. "In five-year 
cycles, we run almost 100 percent of our 
science staff through the minisabbaticals. 
Wc see it as an opportunity to impro\c the 
pipeUne of minorit)' candidates." 

Now, Cabrera says, after playing doc- 
tor in class — measuring blood pressure, 
temperature, and heart rate — her stu- 
dents are more interested in details when 
they \isit their own doctors. A few want 
to become doctors, and one is consider- 
ing a microbiology career. ■ 



Carol Cruzan Morton 
for Focus. 



IS a science writer 



GOING THROUGH THE MOTIONS 



REACHING BEYOND THE SINGLE 

snapshot of a protein frozen in a 
revealing position, structural biologists 
and colleagues at HMS are planning 
new ways to integrate images from a 
range of techniques to provide higfily 
detailed and dynamic views of how 
atoms, small molecules, and large 
protein superstructures move, transfer 
information, and reconfigure in the 
crowded, fast-paced life of a cell. 

This structural biology initiative is 
coming to fruition as the Center for 
Molecular and Cellular Dynamics, 
which builds on a critical mass of 
structural biology and closely related 
expertise on the Quad and at affili- 
ated institutions. The center also 
reflects a trend in biology to find 
meaningful ways to integrate the 
growing "parts list" of genes, pro- 



teins, and molecular structures to 
improve understanding of human 
health and disease and to display if 
in useful ways. 

Leaders of the effort envision first 
developing methods for generating 
and analyzing "molecular movies" 
integrated in a model that can be 
viewed on a similar range of scales. 
Scientists wont to be able to zoom in 
on commingling atoms and zoom out 
to membrane proteins, oil in motion 
and over time, and eventually use the 
model as a research tool itself. 

"Our intellectual goal is to figure 
out how cells work," says center direc- 
tor Stephen Harrison, Howard Hughes 
Medical Institute investigator and 
HMS professor of biological chemistry 
and molecular pharmacology. ■ 

— Carol Cruzan Morton 



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WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



J r L J I i iT/ Fj 



MAKING THE ROUNDS AT HMS 



Mocking the Docs 




ROPSY, A STOUT MAN, COURTS 

Consumption, a coy but 
withered young woman. A 
fire-snorting beast chews on 
a foot affUcted with Gout, while tiny 
cavorting creatures offer tasty treats to 
a man with Indigestion. A group of sur- 
geons — including Sir Dreary Dropsical, 
Doctor Peter Putrid, Samuel Sawbone, 
Frederick Fistula, Sir Jaundice Jollop, 
and Launcelot Slashmuscle — serenely 
saw away at the leg of an agitated man. 
These images are all examples of 
graphic satire, which enjoyed great pop- 
ularity, especially in Britain, in the late 
eighteenth and early nineteenth cen- 
turies. This was the time of the Enlight- 
enment and the Industrial Revolution. 
Rapid and significant changes in poHtics, 
economics, social structure, rehgious val- 
ues, and scientific knowledge were creat- 
ing anxiety among the public. As they 
rose in status, the emerging managerial 



and professional classes — 
including politicians, bar- 
risters, academics, scien- 
tists, and physicians — 
became targets of both 
public resentment and the 
satirists' wicked wit. 

Caricaturists of that era 
often used ailments — such 
as consumption, gout, indi- 
gestion, and depression — 
as metaphors for greater 
social and political ills. Few 
subjects, in fact, proved 
more tempting to the 
satirists than doctors and 
disease. The satirists' zest 
for lampooning medicine 
arose in part from expecta- 
tions generated by the rapid and signifi 
cant transtormation of medical knowl 
edge that accompanied the broader 
changes of the era. 





WELL-TURNED CALVES: Edward Jenner's use of cowpox to vaccinate against small- 
pox provoked the ridicule of satirist James Gillray, >vho merrily portrayed Jenner's 
human subjects turning into cows upon inoculation. But this time the artist's skepti- 
cism was misplaced; Jenner's discovery was one of the first truly effective treat- 
ments developed by emerging scientific medicine. 



///' rUo/ir 



THE DEVIL IS IN THE ENTRAILS: George Cruikshank 
depicted "The Cholic" as a maiden lady alarmed by 
the frenetic demons tugging at her abdomen. 



The eighteenth century saw ancient 

models of classical humoral pathology 

beginning to crumble in the face of mod- 
el o 

ern theories based upon the scientific 
method. But the gro\\Tng body of med- 
ical knowledge would not produce 
effective treatments for many years. 
Bleeding, purging, and other "heroic" 
measures — remnants of earlier medical 
practice — would persist well into the 
nineteenth century. The bitter reahty 
that medicine's new knowledge had yet 
to yield significant improvement in the 
treatment of disease and suffering made 
physicians ripe targets for comparison to 
other powerful but not always effective 
members of societ); such as politicians. 
The Rare Books and Special Collec- 
tions Department of the Francis A. 
Countway Library of Medicine, which 
houses approximately 300 of these 
lively and gleeful prints, recently 
mounted an online exhibit that features 
the highlights of this collection. Artists 
include such prominent caricaturists as 
WUliam Hogarth, Thomas Rowlandson, 
George Cruikshank, and James Gillray 
To adniire the satirists' handiwork, \'isit 
http://countweb.mcd.harvard.edu/ 
ratebooks 'satires. ■ 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



PHESTDF NT^S REPORT 






n 



UST NORTH OF VANDERBILT HALL 

Stands a new structure now 
known as the NRB, the New 
Research BuOding, but surely 
awaiting a more distincti\'e name once a 
generous donor is found. It is adjacent to 
another recent structure, the Harvard 
Institutes of Medicine, or HIM, which 
arose from the foundation of what was 
Boston Enghsh High School. 

HIM broke new ground by housing 
scientists from HMS and several of the 
affiliated hospitals, reflecting the intel 
lectual cooperation that crops up not 
infrequently and happUy ignoring the 
competitiveness that can surface in the 
clinical arena. The NRB will add more 
than 400,000 square feet of research 
facilities, to be shared among the Long- 
wood family members. It will also bless 
the (acuity with a large auditorium and a 
long needed conference center. 

The NRB is not the only addition to 
research space in these parts. Children's 
Hospital is adding 300,000 square feet. 
And it appears that the minuscule Judge 
Baker structure has been sold to a devel 
oper whose currently known plans envi 
sion a research building of up to 400,000 
square feet. Add to that some 466,000 
square feet that Merck is putting up on 
the Emmanuel College campus, plus a 
major addition across town by Massa- 
chusetts General Hospital, and one 
begins to wonder whether Boston's "Big 
Dig" will accommodate the traffic added 
by this enthusiastic burgeoning of 
research capacity alone. And there are 
mutterings implying even more! 

The rub, of course, is whether we can 
fill all that space. Yes, with people — after 
all, nature abhors a vacuum — and excel- 
lent people at that, but can we generate 
the dollars to handle the costs? The dou- 
bling of the National Institutes of Health 
budget, announced se\'eral years ago, is 
drawing to a close, but even if the future 
had been meant to be a straight-line 
extension of the past, the future is not 
what it used to be, given the economic 
situations of governments federal and 
local, the tempered return on endow 



ment, tensions abroad, and restix'eness at 
home. Even in good times research grants 
tend not to pay the full costs of a vigor- 
ous research establishment, and those 
prayed-for exceptional income streams — 
the big scores in technology transfer that 
generate major commercial royalties — are 
few and far between. 

Another potential challenge may arise 
from the growing proximity of pharma- 
ceutical and biotcch firms. Lea\ing aside 
any useful scientific dialogue, they may 
promise mouthwatering discrepancies 
in salaries for researchers from principal 
investigators to bottle washers. And 
despite the valid caution that he who rides 
the tiger cannot dismount, the inability 
to resist blandishments from such firms 
can generate major disruptions in the 
progress of scholarship in academia. 

So, the clinicians among us HMS 
alumni across the nation feel pushed 
about by forces beyond our control, and 
comparable disquiet may well be mount 
ing in our campus research community. 
How we deal with these forces will like 
ly be critical in shaping the nature of the 
School over the next few decades. Would 
that we could address the interaction 
with our environment with as much 
facility as we are moving into molecular 
biology, and respond as rationally. 

By the way, if you haven't shared your 
email address with us, we'd love to have 
it — not to add to the spam you now 
receive, but rather to foster timeliness 
and thrift in the communications we 
offer you and to cultivate virtue in our 
responsiveness to requests and ques- 
tions you might toss our way. Please 
send your email address to nora_ 
nercessian@hms.harvard.edu. 

And if you haven't checked out our 
HMS alumni website, don't miss the 
opportunity to stay tuned. It's www. 
hms.harvard.edu/alumni. ■ 

Mitchell T. Rabkin '55 is an Institute Scholar at 
the Carl ]. Shapiro Institute for Education and 
Research at HMS and the Beth krael Deaconess 
Medical Center as well as chief executive officer 
emeritus of Beth Israel Hospital and CareCroup. 




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WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



'ROOKMAHK 



10 



I REVIEWING THE PRINTED WORD 



An Arrow Through the Heart 



One Wbmtin's Storx of Life, Love, and Surviving 

a Near Fatal Heart Attack 

by Deborah Daw Heffernan (Free Press, 2002) 

LIFE BEGAN AND NEARLY ENDED ONE DAY IN MAY IQQ/ FOR 

the author of An Arrow Through the Heart. Deborah Daw 
Heffernan was 44 years old, a partner in a corporate train- 
ing company, ecstatically married, with a regular mat at the 
yoga studio and not one cigarette to her name. Then, in the 
middle of an advanced stretching class ("a warming pose"), 
she had a massive and idiopathic LAD artery dissection. 

The young, nutritionally careful, cardiovascularly fit, 
and premenopausal author almost died, but instead sur- 
vived to write about what she describes as her "year's 
stay in the monastery of illness." This is not 
an educational book in any traditional way 
(for instance, there is no appendix of angi- 
nal symptoms specific to women, even 
though Heffernan notes that more women 
than men die of cardiac disease, and more 
women die of cardiac disease than all other 
causes combined). It is instead the 
unabashedly passionate book that her life has 
been waiting for her to write. 

"Disease," she begins in the prologue, in a 
lively, often light way, "becomes a diagnostic 
tool for the spirit." The facts follow. After 
unsuccessful emergency angioplasty at Mount 
Auburn Hospital, she is taken to Massachu- 
setts General Hospital, where she receives a 
double bypass in the middle of the night. She is 
left with permanent cardiomyopathy, residual ventricular 
tachycardia requiring AICD (automatic implantable car- 
diac defibrillator) placement, an ejection fraction of 25 per- 
cent, and a ticket for transplant. 

It takes Heffernan more than 100 pages to cox'er just 
four weeks of surgical recovery before leaving MGH. There 
is ICU psychosis (a term actually coined there, I believe) 
and dawning consciousness of her condition. There is 
dependence so absolute that her bowels are grateful when 
a nurse "swoops a bedpan beneath me with the flourish of 
a waiter pulling out a chair"; she is "reduced to being 
thrilled with a sponge bath." There is the evidence itself: a 
scar like "a mountain ridge" rising from stomach to clavi 
cle. There are sequential accomplishments; first meal, first 
pee, first walk. 

The book is a diary, but just as importantly, a love story. 
Heffernan is in love many times over — foremost \\'ith her 
husband and family, but also, and ecjually intensely, with a 




number of HMS alumni. Since complaints are the most 
common form of communication between patient and 
doctor these days, unblushing adoration must feel very, 
very good to receive. It certainly feels good to read. "I am 
always giddy with the doctors who saved me," she writes, 
"a medical groupie." 

HMS is no slouch when it comes to its alumni. In med- 
ical journals and press releases, their accomplishments are 
described admiringly and sometimes reverentially. But 
never have they been described so downright tenderly. Car- 
diologist Marc Semigran '83 has "the dimpled rosy cheeks 
of a shepherd boy in a Renaissance painting" (find that any- 
where else in his resume). Cardiac surgeon David Torchi- 
ana '81 is "my torch of light." Psychiatrist Ned Cassem '66 
"glow(s) from within like an apricot." Each specialist 
_ inflames her: "When they are near, I am an 
^— -^'' exploding piiiata. Candy and messy emo- 

j^^^0r tions are everywhere." 
^^^^ When Heffernan and her husband leave 

^^F the loving arms of MGH (a new identity for 

wP that aristocratic place), she cannot pull, 

" , J push, shove, lift, or hang laundry. They 
relocate to their summer home in Maine, 
where she is "a bag of bones embarking 
on...adventure." The months on those high 
seas of reco\'ery include making peace \\ith 
AICD ("now my enemy and best friend") 
and its constant potential to deliver the 
shock of her life, consulting osteopaths and 
massage therapists, studying the Tibetan 
Book of the Dead, potting plants with 25 
percent of previous aerobic capacity, and a return 
to the warming poses of yoga. There is spiritual realign- 
ment, as one might expect, and other genuine augmenta- 
tions to being a traditional medicine groupie (except for 
herbs — e\'en peppermint tea is forbidden). 

Reading about catastrophe is always a dilemma; ho\\- can 
you enjoy a book about someone's physical suffering? But 
here you follo\\' the example of Heffernan, who enjoys her- 
self in odd, articulate, and hard -won ways. The Dalai Lama 
is rumored to giggle a lot, and you get the idea that this 
author wouldn't hold anyone's guffaw against them. Sub- 
lime humor, that high defense, is on the list of treatments 
she has picked. 

The book ends with six pages of single-spaced acknowl 
edgments and one tender example; "I thank all of you from 
the bottom of my half-a-heart. Please eat your vegetables 
and walk xigorously for 30 minutes every day, reducing 
your chances of getting heart disease by 40 percent." No 
punchline could be sweeter. ■ 

Flissa Flv 'SS is a lecturer on psvchiatrx at HMS. 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



BOOKS BY OUR ALUMNI 



ROOKSHET.F 



THE 
HARNARD^ 

■Qmii^icai 
sciiooi nM 

jiiClIin TO 
^^lll Mill 




is ^re^ner 
in ^Ptir 

Own 



9«« 




CHANGE 

\OUR LOOl^, 

CHANGE 

YOUR LIFE 



The Harvard Medical School 
Guide to Men's Health 

by Han'ey B. Simon '67 (The Free Press. 2002) 



This comprehensive manual, based on 
results from HMS and Han-ard School of 
Public Hedth studies of more than 96,000 
men follow ed for up to 25 years, aims to 
help men overcome the disparity' between 
male and female longe\'ity. The author 
reviews the health needs of men and dis- 
cusses risk factors and prc\enti\e mea 
sures related to the three leading causes of 
death in American men — coronary artery 
disease, stroke, and cancer. He also exam 
ines male-specific diseases and offers a 
program to help men stay healthy. 

Doctoring Together 

A Physicians Guide to Manners. Duties, and 
Commumeation m the Shared Care of Patients 
by John D. Stoeckle '47, Laurence J. 
Ronan '87, Linda Emanuel '84, Carol 
Ehrhch, and Cynthia Cardon Hughes 
(Massachusetts General Hospital. 2002) 



The authors, colleagues in the Primary 
Care Program at Massachusetts Gener- 
al Hospital, offer guidelines for commu 
nicating effccti\ely and building strong 
professional relationships. They explore 
doctor/doctor interactions, as well as 
relationships between doctors and resi- 
dents, students, and nurses. They stress 
the importance of showing interest in 
the work of other physicians, mentoring 
physicians-in-training, and sharing the 
care of a patient with colleagues. 



The Grass Is Greener in 
Your Own Backyard 

by Carla Newbern Thomas "82 
(Dorrancc Publishing Co., 2002) 



Thomas presents a compilation of reh 
gious-themcd poems and songs, as well 
as short stories based on her medical 
experience. Reflecting her background 
in working with adolescents, her w riting 
deals with the dangers young people 
face. It reaches out to them, urging them 
to make the right choices in their li\'es. 

Metabolic Regulation in Mammals 

by David XL Gibson '48 and Robert A. 
Harris (Taylor 6~ Francis, 2002) 



In a concise companion text for life sci 
ence students, the authors provide an 
introductory o\erview of the control 
mechanisms that regulate metabolic 
flows in mammalian cells and tissues. 
They follow this introduction with four 
chapters focusing on individual tissues 
and the interplay among tissues: red 
blood cells, muscle, adipose, and liver. 

Dermatology for Clinicians 

A Practical Guide to Common Shm Condi 
lions, by Massad G. Joseph '77 (Parthenon 
Publishing Group, 2002) 



A reference guide for primary care 
physicians whose patients present with 
skin problems, this book outlines 
common dermatological conditions — 



including psoriasis, herpes, acne, scars, 
fungal infections, and skin cancers — 
and provides step-by- step, detailed 
instructions for diagnosis and treat 
ment. The author offers both basic and 
advanced approaches to managing com 
mon skin problems. 

Cell Biology 

by Thomas D. Pollard '68 and William 
C. Earnshaw (W.B. Saunders Co., 2002) 



This undergraduate textbook, wliich is 
also appropriate for graduate and med- 
ical students, presents the latest devel- 
opments in the field of cell biology, 
emphasizing macromolecular interac- 
tions and their relation to cellular struc- 
ture and function. The book features 
color illustrations and includes cUnical 
examples that depict how cell biology 
explains human disease. 

Change Your Looks, Change Your Life 

9uick Fixes and Cosmetic Swxerx Solutions 
for Loohdng Younger Feeling Healthier, and 
Living Better, by Michelle Copeland '77 
(HarperResourcc, 2002) 



This guide to cosmeric procedures covers 
surgical options, including faceUfts, hpo- 
suction, and breast augmentation and 
reduction, as well as nonsurgical choices, 
such as laser treatments and botox injec- 
tions. The author, a plastic surgeon, 
explains each available procedure and 
discusses preparing for and reco\'ering 
from .surgery. She also includes a chapter 
for men considering plastic surgery. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



11 



RKNCHMARKS 



I DISCOVERY AT HMS 



Don't Change Your Tune: New Surgical Techniques Spare the Voice 




D 



T IS HARD TO BELIEVE THAT THE 

source of the purest, sweetest 
singing voice is two small folds 
of tissue drubbing together at 
high speed in the middle of the throat, 
and that e\'en the most delicate aria is 
born of pressure and force. The vocal 
cords move together and apart in a wave, 
from bottom to top. Repeat this contact 
100 to 1,000 times a .second and you have 
a voice that can produce exquisitely var- 
ied sounds. But too much strain can leave 
flaws in this delicate system, and when 
bumps, cysts, or cancers arise in the vocal 
cords, a patient's voice is at stake. 

Innovations in \'ocal cord surgery ha\'e 
helped improve the odds of eliminating 
these problems without sacrificing the 
voice. Steven Zeitels, HMS associate pro 
fessor of otology and laryngology and 
director of the Division of Laryngology at 
the Massachusetts Eye and Ear Infir 
mary, has been a leader in developing 
increasingly precise phonosurgical tech 



niques. Much of the past decade 
of these innovations is detailed in 
two papers in the December issue 
of Annals of Otolog)', Rhinology & 
Laryngology, which look at two 
groups of patients: those with 
early vocal cord cancer and 
singers and orators who dexelop 
lesions on the vocal folds. 

Speak Easy 

Surgery of the larynx lends itself 
to minimally in\-asi\'e techniques. 
0\'er the past 25 years or .so, endo- 
scopic surgery has replaced open 
surgery in a large number of lar\Ti- 
geal cancer cases. The surgeon 
vie\\'s the vocal cords through a 
microscope and removes cancer- 
ous tissue \\Tth specially elongat- 
ed instruments and sometimes a 
carbon dioxide laser as well. 

Even with improvements in 
instrumentation, surgery general- 
ly has been viewed as less desir- 
able than radiation in the treatment of 
early vocal cord cancer. Both ha\'e high 
cure rates, but radiation is thought to 
result in less damage to \'ocal cords. Zeit- 
els and his colleagues have spent the past 
decade evaluating this issue and boosting 
the role of surgery by exploring tech- 
niques to perfect more precise resections, 
remove smaller amounts of tissue, and 
reconstruct tissue when needed. "In fact, 
some studies have demonstrated that 
over time, radiation can cause fibrosis and 
stiffness of normal vocal fold tissue," Zei- 
tels says. "The goal is to preser\'e the nor- 
mal tissue since this is the primary \'oice 
source. So radiation treatment for early 
cancer is conceptually fla\\'ed because it 
targets both the normal and cancerous 
\-ocal cords indiscriminately." 

Zeitels believes the poor \o\cc out 
comes of surgery are not necessary in 
many cases. "What we learned about 
cancer patients in the early '90s is that 
their management was frequently not 



done with the optimum amount of preci- 
sion," he says. "Often the approach con- 
sisted of overtreatment." Part of the 
uncertainty lay in not knowing the depth 
of the tumor in the tissue. Cancer exci- 
sions confined to the superficial layers of 
the folds were much less damaging to the 
\'oice than those including the underly- 
ing muscle and \ocal ligament, which 
may compromise the ability of the folds 
to close. Zeitels developed the technique 
of infusion, in which liquid is injected 
into the subepitheHal tissue; if the tumor 
rises, it has not yet im'aded the ligament 
and musculature. He found that many 
early cancers were shallow and required 
less tissue removal. 

The latest study gathered vocal out 
come data for a group of 32 patients 
undergoing phonosurgery for early can 
cer of the vocal cords. Infusion showed 
that nearly half needed only superficial 
resections. Of the others, nine required 
reconstruction, which im'oh'cd Upoinjec- 
tion or a Gore Tex implant to fill out the 
folds. All of the patients are free of cancer 
without radiation or open surgery, and 
most achieved conversationally normal 
\'oiccs after the surgery. 

Occupational Hazards 

Singers and vocal performers put a stress 
on their \-ocal cords akin to the physical 
exertion of a marathon runner. With their 
\-ocal folds \ibrating at full \olume for long 
periods of time, singers and orators often 
de\'elop bumps, pol)ps, and rough surfaces 
on the tissues. These lesions can damage 
the x'oice that for man\' is also a lix'cUhood. 
Although surgical remo\'al is possible, 
there is a chance that any excision will per 
manently alter the \oice. Zeitels set out to 
study this patient population more sys 
tematically. UntU his recent study, there 
was little data to determine the success of 
surgical management in vocahsts. 

Llsing an approach called stroboscopy, 
the surgeon can assess the \'ibratory func 
tion of the \-ocal cords. A strobe Ught ere 



12 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



atcs the illusion of slowing down the 
rapicll)' \-ibrating cords and allows the 
observer to watch them mo\e together 
and apart, \bice outcomes of the surgeries 
in both studies were evaluated by Robert 
Hillman, HMS associate professor of otol 
ogy and lar)Tigology and a \'oice scientist 
who leads the \'oicc lab at the Massachu 
setts Eye and Ear Infirmary. Hillmaris 
group primarily tested two general met- 
rics of the voice: acoustic measures such as 
loudness, pitch, and regularit)' of tone, 
and aerodynamic measures — how much 
air the person must push from the lungs to 
get the vocal cords to \dbrate. 

In the cancer patient group, many of the 
measures taken before surgery were 
abnormal but showed significant impro\'e 
mcnt after the procedure and some voice 
therapy. For the group of 185 singers and 
performers, Hillman says, the voice mea 
surements were trickier. The metrics of 
normal and abnormal ranges are designed 
for the general population, not the exact 
ing standards of a performer. "It's not 
surprising that the measures we used to 



indicate a range of normal limits may not 
be as sensiti\'c in this group," he says. The 
team did find, however, that the few- 
abnormal measures improved after 
surger)', and eight of the 24 objective mea- 
sures showed statistical improvements 
across the group. The surgery did not 
cause any measures to drop below the nor 
mal range, and nearly all the patients 
thought their voices had improved. The 
study helps bring data to a patient popula 
rion that often approaches treatment with 
trepidation, unsure if treatment outcomes 
are worth the risk of worsening the \'oice. 

Zeitels believes that the two studies, 
though \ery different in t)'pe of patient, 
represent a convergence of surgical 
approaches. His team found that "when 
w'e managed the cancer patient with the 
precision that you manage the performer, 
we could enhance the voice outcome 
without sacrificing oncologic efficacy." 

Singers, like athletes, offer a model for 
stud)ing how different beha\'iors affect 
the vocal cords: a musical- theater singer 
who belts out Broadwav numbers is cre- 



ating a different kind of stress than an 
opera singer. "If you can understand how 
these indi\iduals function, you can mas 
ter restoring most other voices," Zeitels 
says. He has found that singers can often 
perform with long-term trauma because 
their acti^^ty has induced more elastic 
normal tissue to compensate — their 
\'ocal cords even appear larger. The team 
has a partnership with Robert Langer, an 
HMS senior lecturer on surgery at Chi 
dren's Hospital and the Kenneth J. Ger 
meshausen Professor of Chemical and 
Biomedical Engineering at MIT, to de\-el- 
op biomaterials that could be used to 
reconstruct this elastic tissue. 

The trick, Zeitels says, is to find a mate- 
rial that does not degrade and is pliable, 
since stiffness is the cause of the majority 
of hoarseness. He believes that maintain 
ing or even .supplementing the healthy tis- 
sue may become just as important in \'ocal 
surgery as removing the abnormalities. ■ 

Courtney Humphries is a scienee writer 
for Focus. 



LIVING LARGE TAKES A BITE OUT OF LIVING LONG 




evere caloric restriction is known to promote longevity 
in loboratory animals, but researchers have wondered 
whether a drastic cutback in food is really necessary 
for long life. Food-deprived rodents exhibit a host of 
characteristics, such as low body fat, and alterations in the activity 
of proteins, such as insulin. If body fat and insulin activity could be 
reduced by some other means, might animals live longer while eat- 
ing all they liked? The answer, it appears, is on appetizing yes. 

Matthias Bluher, Barbara Kahn, and C. Ronald Kahn followed 
the fates of mice lacking the gene for a protein involved in insulin 
activity, the fat-specific insulin receptor. The mutants exhibited a 
50 to 70 percent reduction in body mass throughout their lives. 
And they were considerably longer lived. For example, 80 per- 
cent of the knockouts were alive at 30 months, compared to 50 
percent of controls. Many mutants lived well beyond that point. In 
their study in the January 24 issue of Science, the scientists report 
that the knockouts' mean lifespan increased by 3.5 months. 



Most significant, the mutants achieved all this without diet- 
ing. In fact, the knockout mice ate significantly more than their 
wild type littermates. "Leanness, not food restriction, is a key 
contributor to extended lifespan," write Bluher, on hIMS 
research fellow in medicine, and C. Ronald Kahn, the Mary K. 
lacocco Professor of Medicine, both at Joslin Diabetes Center, 
and Barbara Kahn, on HMS professor of medicine at Beth 
Israel Deaconess Medical Center. 

Flow, exactly, leanness promotes longevity is not clear. One 
possibility is that reduction in body fat lowers production of 
oxygen free radicals associated with aging. Another possibility 
is that alterations in insulin signaling ore responsible for the 
gain in longevity. Mutations that reduce insulin-like signaling in 
worms and flies hove been shown to increase life expectancy. 
"The exact mechanism underlying this effect requires further 
analysis," write the authors. ■ 

— Misia Landau 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



13 




F TOUCH TITHEALIN 



COVER STORY 



IN 1816, RENE LAENNEC, AN EXPERT IN CHEST DISEASES, WAS 

examining a plump young woman with heart prob- 
; ;{■ ■ lems. Painfully shy, the doctor could not bring himself 
. • ■•;. V ; to press his ear to her chest, the only known method 
; of auscultation. Remembering a childhood trick of 
scratching the end of a log with a pin to amplify a 
sound, he rolled sheets of paper into a cyhnder. When 
1^ applied one end of it to the woman's chest and the 
Us surprised to find that he could hear her heartbeat 
arly. He went on to invent the monaural stethoscope. 
"Before Laennec's discovery, touch had been unquestioned in the doc- 
tor's interaction v^th the patient," says Lucy Candib '72. "When stetho- 
scopes first came into use, many doctors were even offended by the idea 
of inserting something mechanical between themselves and their 
patients. Since then, however, medicine has become increasingly ambiva- 
lent about touch. Based on customer input, Littmann recently lengthened 
the tubing of its stethoscopes because of practitioners' 'desire to distance 
themselves from sick patients, as well as ergonomics.'" Today medicine is 
asking new questions about an ancient practice: how is technology shap- 
ing clinical touch, and what aspects of clinical touch should resist change? 



.ARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



.*f;^^^,fc.u>^y'^»H.^-■-w«!p:py»?^ ,.^fg^,^^s^»^^ 




MOTHER NURTURE: 
Researchers have sho^n 
that early nurturing 
touch is essential to the 
normal development of 
humans and other pri- 
mates. Here, a baby 
monkey takes comfort 
from a terry-cloth mother 
which, researcher Harry 
Harlot found, provided 
more benefits than mere 
wire-frame mothers. 




"St' 



V 





OF TOUCH IN HEALING 



From neurobiology to surgery to family 

medicine, science is transforming 

applications of touch by BEVERLY Ballaro 




AN ERA WHEN SPACE AGE 



technologies are transforming the role of touch in healing, Mary 
Carlson, associate professor of psychiatry at tiMS, has turned to 
some of science's most sophisticated tools to demonstrate the pri- 
macy of a decidedly low-tech factor in human development: the 
nurturing touch essential to every child's capacity for physical 
and mental health. 



Carlson's career-long fascination with the role 
of touch reaches back to the late 1950s and her 
freshman year at the University of Wisconsin 
when she took an introductory psychology 
course with Harry Harlow. Carlson, who had 
assumed that infants of all species were genet 
ically programmed to progress to normal 
adulthood, was amazed by the results of Har 
low's famous experiments with monkeys. 

"Harlow's research clearly showed that if a 
baby didn't get maternal affection, it didn't 



become what we normally think of as a mon- 
key," Carlson says. "Even if baby monkeys 
could see, smell, and hear other monkeys — but 
not touch them — they still turned into bizarre, 
pathetic creatures." 

Carlson spent much of the next two decades 
of her career trying to figure out why and how 
a lack of maternal touch could lead to such 
devastating — and permanent — damage. "It 
seemed an intuitive and logical idea that early 
sensory stimulation affected the ner\'ous system 



WINTER 2003 • HARVARD MEDICAL AlUMNI BULLETIN 



17 



es|P;e the diet, medical care, and sanitary conditions, gre^ 
numbers of children consigned to state care displayed 
stunted growth and grossly delayed speech and motor skills 



and, specifically, the development of the 
brain pathways and organization. Con- 
sequently, a lack of touch would lead to 
abnormal pathways. So I spent many 
years studying the areas of the cerebral 
cortex that mediated touch to see how 
they might be disordered as a result of 
different levels of maternal touch." 

Carlson created highly intricate, 
detailed maps of the brain in her quest 
to sort out the links between primary 
sensory pathways, early deprivation, 
and beha\ior. Taking a cue from other 
researchers' experiments — in which 
they covered one eye of a newborn pri- 
mate and subsequently learned that 
doing so would cause the brain to devel- 
op compensatory pathways — Carlson 
tried analogous experiments in the early 
1990s in which she outfitted one hand of 
a baby monkey with a glo\'e. To her sur- 
pri.se, unlike in the case of partial \'isual 
depri\'ation, in cases of partial tactile 
depri\'ation, a monkey's brain organiza- 
tion appeared normal when the glo\'e 
was removed. This pointed to some 
mechanism at work other than the .sen 
sory pathways that had long been the 
focus of Carlson's investigation. 

"My first question was: if it's not the 
sensory pathways, then what is it?" 
Carlson says. "My second question was: 
what am I doing in a lab with mon- 
keys?" Apart from the stresses of study- 
ing the role of touch in primate de\'el- 
opment at a time when some animal 
rights activists were beginning to tar- 
get neuroscience researchers — some of 
her colleagues and their children 
received death threats — the pohtical, 
as well as medical, implications of 
touch research v\'ere becoming more 
starkly apparent to Carlson. "I wasn't 
interested in making it my life cause to 
support ethically conducted animal 
research," she says. "I wanted to focus 



on issues affecting the quality of life for 
children. I began to see connections 
between v\'hat we were learning in the 
laboratory about touch and the lives of 
children in the real world." 

Those connections began to take 
shape in Carlsons mind partly as a 
result of work done by researchers who 
had begun to identify the crucial role 
of touch in establishing the regulatory 
functions of stress hormones. Their 
research showed that if newborn rats 
did not receive touch stimulation dur- 
ing an early, critical window, they 
would suffer impairment of the hypo- 
thalamic-pituitary adrenal axis, the 
body's major endocrine stress pathway. 
This would lead to lifelong o\'ersecre- 
tion of the stress hormone Cortisol in 
response to daily life challenges. 

Because Cortisol works to dampen 
the physiological consequences of stress 
by suppressing the body's energy- 
expensive systems for growth, digestion, 
and immunity, an overabundance of the 
hormone could ha\'e adverse effects on 
normal development. The homeostatic 
mechanisms of deprived animals would 
tend to get stuck in overdrive, and their 
inabihty to manage their stress efficient 
ly would lead them to exhibit both brain 
and behavioral deficits. 

"i began to wonder: ha\-e I been look 
ing in the wrong place all these years?" 
says Carlson. "Maybe the HPA axis is 
the key. Maybe it's the adrenal cortex — 
and not the cerebral cortex — that holds 
the answ^er as to why an early lack of 
touch can have such devastating conse 
quences for the de\'eloping young." 

The Surreal World 



Carlson found an opportunity to trans- 
late this new understanding of the 
importance of touch in dramatic and 



practical fashion when the 1989 col- 
lapse of Nicolae Ceausescu's authori- 
tarian Communist regime in Romania 
permitted outsiders their first extend- 
ed look inside a nation that had been 
largely sealed off from the world for 
decades. In his maniacal zeal to trans- 
form Romania into an industrial power, 
Ceausescu had imposed draconian 
mea.sures for the purpo.se of coercing 
the largest possible future work force 
out of the country's population. 

Children whose overburdened par- 
ents could not care for them became the 
property of the state. Before long, not 
just po\-erty but any perceived anomaly 
could land a child in a residential insti- 
tution, called a Icaganc, or "cradle." Such 
institutions, according to the regime's 
propaganda, represented a fine, e\en 
humane, alternative — a view widely 
shared by mothers and pediatricians 
attempting to cope with the stress and 
guilt that stemmed from separating 
children from their parents. 

"In many ways," says Carlson, "what 
was taking place was rationalization 
and denial on a massive scale. Mothers 
would console themseh-es by insisting, 
i'll come back and visit.' Doctors 
would take pride in the medical 
approach to the institutional care pro 
\ided to the children; there was an 
enormous emphasis placed on hygiene, 
nutrition, antiseptics, and antibiotics. 
The popular perception of state institu 
tions as places where kids recei\'ed food 
and medicine not necessarily a\'ailable 
to other people in a country as de.sper 
ately poor as Romania e\en led to wide 
spread resentment of institutionalized 
children — not unlike the ways in 
which some in our own society dispar 
age welfare recipients." 

Despite the diet, medical care, and 
sanitary conditions — better than ade- 



18 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 




quatc by Romanian standards — great 
numbers of children consigned to state 
care displayed stunted growth, grossly 
delayed speech and motor skills, and 
other evidence of a failure to thri\'e. The 
harried caregi\'ers — o\-er\\helmed by a 
t)'pical load of 12 to 20 children per 
adult^could act as little more than 
custodians and were not in a position 
to question institutional practices. The 
staffs did not include any nurses, psy- 
chologists, or socid workers, as Ceaus- 
escu had eliminated these professions 
in his contempt for "soft" disciplines 
and his desire to channel all resources 
into the hard sciences that would ben 
efit heavy industr\'. 

The only people who might ha\e 
made an issue out of so many children 
failing to meet so many de\'elopmental 
milestones were the pediatricians. But 
many pediatricians, says Carlson, also 
rationalized away the phenomenon by 
operating on the assumption that the 
anomalies that had led some children to 
institutional care in the first place — 



and not the conditions of that care — 
accounted for the children's problemat 
ic development. 

It fell to pediatricians to make judg 
ments on the children, once they had 
reached the age of three, as to whether 
they should be classified as "irretriev- 
able" or "educable." The "irretrievables" 
would be warehoused in other state 
institutions until their 18th birthday, at 
which point they would be dumped into 
society to fend for themselves. Many, it 
was whi.spcrcd, found their way into the 
ranks of the Sccuritatc, the feared Roman 
ian secret poHce; their stunted emo- 
tional de\'elopment and attendant lack 
of ability to form social attachments 
made them uniquely suited, some sus- 
pected, to the brutal nature of the job. 

Not long after Ceausescu and his 
wife — hurriedly tried and comicted by 
a military tribunal — were executed by 
a firing squad on Christmas Day of 
1989, life inside Romania's orphanages 
became subject, for the first time, to 
outside scrutiny. Among those trans- 



fi.xed by the disturbing images that 
began to emerge — of sUent, swaying 
children staring vacantly into space — 
was Mary Carlson: "When I saw those 
scenes out of the orphanages, some 
thing clicked. I realized that the affects 
and behanors of those children bore a 
striking resemblance to those of the 
autistic-like monkeys who had been 
deprived of maternal touch and nur- 
turing early on." 

Spitting Images 

Carlson recognized that Romania rep 
resented a real-world opportunity to 
put to the test what she had been study- 
ing for years in the laboratory, in a way 
that might have beneficial social and 
political implications for children. She 
secured grant money from the Milton 
Fund to recruit a team of colleagues to 
join her in working with institutional- 
ized toddlers, who had originally been 
placed in Icaganc care between the ages 
of two and nine months, in the town of 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



19 



lasi, Romania. Carlson worked with 
children in an existing two-year study 
that had randomly assigned some chiJ 
drcn to an enriched caregi\'ing situation 
(one highly physically and verbalh' 
interactive caretaker for e\'ery four chil 
dren) and compared them to a control 
group, in the same institution, recei\ing 
standard institutional care (a single har- 
ried caregiver for every 12 to 20 chil- 
dren). Team members measured Corti- 
sol levels by collecting samples of the 
children's saliva to understand their 
daily patterns and to test their respons- 
es to the stress of social events. 

The readings confirmed that the Corti- 
sol levels in the control group reflected 
hormonal profiles typically seen in peo- 
ple suffering from depression or post- 
traumatic stress disorder. When the 



children were subjected to a stressful 
e\'ent — a physical exam conducted by a 
physician unknown to them — their 
stress le\'els not only rose to extreme 
heights, but also took a long time to 
recover. Children with the greatest 
abnormalities in such hormonal readings 
also scored lowest in tests designed to 
measure motor and mental de\'elopment. 
On the basis of what they learned in 
lasi, Carlson and her colleagues were 
gradually able to nudge orphanages 
into adopting reforms. "We con\'inced 
the doctors by appealing to them in sci- 
entific terms they could accept; when 
we showed them the Cortisol results, 
that was real to them, so they were 
more inclined to take action." Among 
the changes instituted: newborns were 
no longer so tightly cocooned that they 



lay immobile in their cribs for hours on 
end, their only human interactions tak- 
ing place when their caregivers would 
change their diapers or prop bottles of 
formula next to them at feeding times. 

The encouragement of greater physi- 
cal interaction and stimulation present- 
ed a major breakthrough considering 
the scene Carlson had t)'pically encoun- 
tered when walking into a Romanian 
orphanage nursery' before reforms were 
instituted. The room would be filled 
with 20 babies all younger than six 
months, but de\'oid of any sounds of 
cr)ang. The babies would he uncarmily 
still and withdrawn in their cribs, star- 
ing \acantly into space. "They had sim- 
ply given up," Carlson says. 

Gi\'en the crucial nature of nurturing 
touch in a child's development and the 




HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



brc\it)- of the window for delivering that 
stimulation to a child, Carlson belie\'es 
that the solution lies not in impro\'ing 
institutions, but in replacing them v^dth 
communit}' based altcrnati\es. 

"It is an ongoing tragedy for count 
less children the world o\'er," says Carl- 
son, "made all the more heartbreaking 
\\hen you think about the enormous 
potential that exists at birth. Humans 
in utero produce twice as many ncu 
rons as surnve by the time a child is 
born. This overabundance — cxuber 
ance, as neuroscientists call it — is just 
as remarkable as the brains plasticit)'. 
The brain has the capacity to compen- 
sate for an amazing amount of damage 
and to recover function. That's the good 
news. The sad news is that this capac 
ity comes at the price of an exquisite 



sensitix'ity early in life; the early capaci 
ty is matched by an early \-ulnerability, 
and prolonged early depri\ation can 
slam the window shut for good." 

What makes the situation even sad 
der, Carlson says, is that while we as a 
societ)' know how to provide remedial 
therapy for lagging cognitive skills, 
medicine still does not understand how- 
to make up for lost early socialization 
opportunities. E\'en if we are eventually 
able to dcN-ise methods to achieve some 
rehabihtarion of early social depri\-a 
tion's de\'astating effects, she argues, the 
human and financid costs of deli\'ering 
such services would be so enormous 
that it would be foolish not to invest 
resources in prevention. 

vSuch choices, Carlson says, have 
already come to the fore globally. While 



Romania has phased out many ol its 
orphanages, a crisis looms in sub-Saha- 
ran Africa, where AIDS has already 
orphaned millions of children. The 
question, Carlson says, is whether this 
disaster will be compounded by herd 
ing these children into institutions. 

"Strengthening communities to help 
socialize orphans can prevent poten- 
tially millions of children from early 
depri\'ation in the first place," Carlson 
says. It is toward this end that she and 
her husband and colleague, Felton 
Earls, have launched a major communi- 
ty-based study on children's mental 
health in East Africa. "Such pre\cn 
tion," Carlson says, "is clearly a more 
pragmatic and far more humane strate- 
gy than attempting to undo the damage 
once it has alreadv been suffered." ■ 




VIR 



A new generation of computer- 
assisted tools is changing the way 
surgeons touch their patients 



LY POSSIBL 





TRAUMA SURGEON KAS BEEN CONSULTED 

on the case of a soldier wounded on another continent. The on-site 
examining chnician shps on a customized virtual-reahty glove that 
collects data on what she is feeling through sensors located in the 
glove's fingertips. This information is stored and then transmitted 
to the faraway surgeon, who can experience the exam in tactile 
fashion and in real time, as if he were conducting the exam himself. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



21 



re's no better presurgical training than playing 
ntendo from the age of two on, and that's pretty 
uch the norm for today's entering students." 



A/1 internist prepares to conduct a 
breast exam on a patient. Using a com- 
puterized, electromechanical palpation 
de\ice, she performs a gentle, non- inva- 
sive exam. The preci.se, objective breast 
density map that emerges becomes a 
storable medical record. By comparing 
these data against the results of future 
exams, the doctor can map and monitor 
any breast changes that occur over time. 

A medical student needs to learn how 
to perform an intubation. Instead of 
practicing the procedure on a man- 
nequin and then switching to real 
patients under close supervision, he 
practices on a virtual reality simulator. 
Through a haptic interface, the simula- 
tor prox'ides him with a realistic tactile 
sensation of the procedure. 

Although these scenarios may read 
to the lay public, and perhaps e\'en to 
some physicians, like fantasies straight 
out of a "Star Trek" episode, they are 
either already reaUties or promise to 
become so in the near future. Medi- 
cine's embrace of the technologies 
made possible by the Information Re\ - 
olution is rapidly transforming what is 
one of the most basic and ancient tools 
of doctoring — the sense of touch. 

One of the pioneers helping to 
speed that transformation is Anthony 
DiGioia III '86, an orthopedic surgeon 
and CO director of the Center for Med- 
ical Robotics and Computer Assisted 
Surgery in The Robotics Institute 
of Carnegie Mellon University and 
the Western Pennsylvania Hospital. 
Although the field of computer assist- 
ed surgery may be young, it promises to 
echpse current approaches to the ways 
patients are diagnosed, undergo 
surgery, and are monitored in recovery. 
"Whereas current surgical practice is a 
relatively loosely connected and some- 
times uncoupled sequence of events," 



DiGioia says, "the next generation of 
surgical tools and technologies will 
include preoperative plarmers and sim- 
ulators ba,sed on three-dimensional 
modeling of a patient's anatomy and 
physiology, thus making possible 
patient-specific plans. In fact, the use of 
computer- assisted technologies will 
influence e\'ery phase of patient care." 

The Surgical Toolbox of the Future 

To bring about this revolution, doctors 
will rely on enhanced versions of exist- 
ing equipment as well as newly invent- 
ed technologies to stock what DiGioia 
refers to as "the surgical toolbox of the 
future." This toolbox, he predicts, will 
include robotic-assisted devices capa- 
ble of precision cutting and position 
ing, navigational and image-guided 
tools that provide real-time informa 
tion to surgeons, micromanipulators, 
and implantable sensors. "Smart" tools 
will optimize presurgical planning and 
the use of simulators to test surgical 
plans. Just as fiber-optic technology 
has made possible every type of scope 
in u.se in medicine today, this new fam 
ily of computer- assisted tools, DiGioia 
says, is being driven by today's informa 
tion technologies. 

Perhaps even more than computer 
assisted tools, it is the surgical informa 
tion systems and "computer vision" of 
augmented reality (sometimes called 
hybrid reality) that promises to pro 
foundly alter the role of touch in the 
surgical profession. Augmented reality 
combines the real world with the \irtu 
al world to display digital images in the 
surgeon's field of vision. During an 
operation, for example, the surgeon 
would be able to "see" bones and tis 
sues that normally would be obscured 
from \iew. This "x-ray vision without 



the use of radiation." as DiGioia 
describes it, gives surgeons the abilit}' 
to use their hands to manipulate instru- 
ments and parts of anatomy in ways 
that would not be possible using con- 
ventional means. 

Adding to these advantages are 
image -guided navigation tools. DiGioia 
likens the technology behind these 
instruments to that employed by the 
global positioning systems built into 
planes and ships. Just as \'ehicles so out- 
fitted still require a captain at the con- 
trols, so, too, do these navigation tools 
require hands-on manipularion by sur- 
geons. These tools complement but do 
not replace the surgeons skills. Their 
advantage is that thev allow surgeons to 
act on real-time information when they 
need it most — during surgery. 

While the shift to new techniques 
remains controversial in some quarters, 
the improved outcomes stemming from 
minimally invasive procedures are well 
documented and sometimes dramatic. 
"Take an operation like the removal of 
a gallbladder, for example," DiGioia 
says. "Years ago, that was an open pro- 
cedure that kept a patient in the hos 
pital for a week and out of work for an 
extended convalescence. Today, that is 
no longer the case. We are already see- 
ing similar kinds of transitions at work 
in orthopedic and cardiovascular 
surgery as well as neurosurgery, and 
we're going to be seeing more and more 
of this trend in many other medical and 
surgical specialties." 

Nintendo Surgeons 

The new touch technology has proven 
remarkably intuitive to the current gen- 
eration of medical students. "Young doc- 
tors are not only comfortable with using 
computers to transform their .sense of 



22 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



touch and add to their ability to use 
information, but they also expect to be 
able do so," says DiGioia. In some ways, 
he jokes, "there's no better presurgical 
training than pla)ing Nmtendo from the 
age of two on, and that's pretty much the 
norm for today's entering students." 

Training and learning, DiGioia points 
out, are already being transformed. 
"Students, residents, and fellows can 
work in real time and get instantaneous 
feedback," he says. "Increasingly, they 
will be able to learn not just on cada\'ers 
but also on computerized substitutes, 
much the way pilots train on fhght sim 
ulators." In some areas, this is already 
the case. With arthroscopic simulators 
that replicate the human knee, for 
example, he says, "If you grab a probe 
and push, the tissue pushes back." 

But, DiGioia quickly adds, the 
strengths that young "Nintendo sur 
geons" bring to the operating room are 
the same talents displayed by their 
more seasoned mentors. "The new 
technology diminishes neither the 
technical challenges of surgerv nor the 
t^ilents required to perform it well," he 
says. "Hand and eye coordination, the 
abilit)' to react efficiently and properly, 
the dexterity to be able to work in 
small spaces — these are timeless attrib- 
utes relevant to both the conventional 
and computer-assisted ways of per- 
forming surgery." 

Like most new trends, this one has 
encountered its share of resistance, 
which DiGioia welcomes as "a sign of 
the healthy skepticism v\dth which all 
good scientists operate." DiGioia has 
found that the biggest hurdle is over- 
coming many of the misconceptions 
associated with new concepts like 
robotics, computer-assisted technolo- 
gy, and na\igation. "For the last sever- 
al )'ears, we ha\e been acti\'ely teaching 




GUT INSTINCTS 



NOT TOO LONG AGO, THE CONCEPT OF USING VIRTUAL REALITY TO AID 
physician learning seenned to belong to the remote future, if not the realm of 
fantasy. Clinicians learned their craft the old-fashioned way — through one-on- 
one apprenticeships, demonstrations by experts, textbook diagrams and 
instructions, and makeshift substitutes for human organs and tissues. 

"When learning, for example, how to perform surgery or endoscopy on an upper 
gastrointestinal disorder," says David Carr-Locke, associate professor of medicine at 
HMS and director of endoscopy at Brigham and Women's Hospital, "trainees would 
often practice on a pig's stomach, set up to appear human." Today's clinicians have the 
option of enhancing their training with computer simulations that reproduce the look and, 
what's most important, the feel of a range of gastrointestinal endoscopic procedures. 

The accuracy of the simulation is not perfect, admits Carr-Locke, who expresses 
confidence that, in a blinded test, he could probably distinguish between real life and 
virtual reality. "But, of course," he adds, "I've done tens of thousands of these exams. 
The point is: could a novice tell the difference? I think not, and this is where the value 
of this kind of haptic technology as a teaching tool comes into play." 

The most useful purpose of haptic simulations, Carr-Locke says, is not to try to recre- 
ate all the subtle and complex pathological variations that might surface in real endo- 
scopic examinations, a range so broad as to make the task of simulating it — in every 
sense — virtually impossible. Rather, he says, the value lies in their ability to remove 
the early part of the learning curve for residents and fellows. 

"It's very much about trying to help someone acquire a basic skill in the most effi- 
cient way possible," Carr-Locke says. "A professional race car driver has to master 
basic driving skills before moving on to more complex challenges. The medical student 
learns instinctively that if he or she takes action X, Y will result." 

Another advantage of the technology, Carr-Locke adds, is that it reduces the stress on 
students and patients alike. Trainees learning to perform a colonoscopy or sigmoidoscopy 
on a computer model can afford to be less tentative than they might be if they were 
nervous about causing discomfort to an actual patient. 

As realistic as some haptic applications ore — simulations can even be programmed 
to scream "ouch!" in response to a trainee's errant touch — Carr-Locke is quick to say 
that they can only supplement, not supplant, the experience of interacting with real 
patients. "Haptic simulations represent but one method in a repertoire of teaching 
strategies," he notes, "and cannot replace the actual clinical encounter." ■ 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



23 



surgeons what these tools do and 
don't do," he says. 

"A hig part of the resistance," DiGioia 
explains, "arises from \'arious miscon 
ceptions about what robotics and com- 
puter assisted surgery mean. Not just 
the lay public but also many surgeons, 
especially those trained at least 20 years 
ago, summon up images of androids 
replacing surgeons. Nothing could be 
further from reality. The idea is to take 
ad\'antage of the different strengths of 
computers and surgeons to complete a 
task better than either machines alone 
or surgeons alone could do." It will 
always be up to the surgeon, he adds, to 
decide what's best for the patient. 



Few would dispute the advantages 
for a patient who undergoes a mini- 
mally im'asive heart bypass procedure, 
or a trauma patient who, thanks to 
new telesurgical applications, may be 
treated by a specialist using robotic 
controls equipped with haptic feed 
back to carry out a procedure from 
afar. Still there are those who grumble 
that the new technology further 
depersonalizes patient 'doctor rela- 
tionships in an era in which cost con- 
straints already afford physicians pre- 
cious few opportunities for hands on 
time with their patients. 

Despite its sci-fi feel, this family of 
technologies could actually enhance the 



patient/doctor relationship, DiGioia says. 
"With this new way of doing things, we 
can craft optimal patient specific surgi- 
cal plans based on an indi\idual's actual 
anatomy. Patients will have more infor- 
mation, and these tools will be able to 
directly measure surgical techniques and 
relate them to surgical outcomes." Small- 
er incisions, he adds, lead to increased 
function earlier, a lower incidence of 
blood transfusion, less pain, and a 
quicker recovery. The unprecedented 
precision may also create fewer compli- 
cations and reduce the need for repeat 
surgeries. "When patients understand 
the implications of the new technolog)-," 
DiGioia says, "they're all for it. Choosing 




A family medicine practitioner 

reasserts the primacy of clinical touch 

and the value of the physical exam 



\Mr 



E RIGHT TOUCH 




N ANTIQUITY, EGYPTIAN PHYSICIANS BELIEVED IN DIRECTLY 

touching wounds to heal them, and the kings and queens of Eng- 
land and France were thought to be able to cure scrohila through a 
laying on of the royal hands," says Lucy Candib 72, professor of fam- 
ily medicine and community health at the University of Massachu- 
setts and a practitioner of family medicine for 27 years. "Yet, despite 
this ancient legacy of the centrality of touch to healing, the modern 
medical profession remains deeply ambivalent about touch." 



24 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



more accurate, less in\'asi\'e techniques, 
with less pain and a faster recovery, is 



excryone s goal." 



Going Hollywood 

The challenge now, DiGioia says, is 
to make the simulations high-fidelity 
enough to look, sound, and feci hke actu 
al surgery. Touch, he points out, is just 
one of the senses that comes into play in 
the operating room, and the effective 
ness of a haptic simulation can be under 
cut if the other stimuli present — the 
sights, smells, and sounds of surger\ — 
are not enhanced enough to allow the 
surgeon to participate in an urgently 



believable experience. For this reason, 
research on improving haptic feed- 
back — producing the accurate sensa- 
tion of tissue or bone resistance — is 
being conducted alongside studies on 
enhancing \isualization. To make things 
look and feel real, the surgical profession 
has turned to a logical resource — the 
entertainment industry — to see if 
Hollywood's famous expertise in cre- 
ating special effects illusions can carry 
o\er into medical education. 

Down the line, DiGioia believes, 
what were formerly major operations, 
such as joint replacements, will become 
less complex as a result of computer- 
assisted tools and technologies. The 



orthopedic profession is already seeing 
an increasing interest in new instru- 
ments, partial replacements, and tissue 
engineering. And eventually, DiGioia 
predicts, biologic implants will replace 
the metal and plastic parts currently in 
use, demanding a new generation of 
tools and techniques. 

"To be able to perform joint resurfac- 
ing with a patient's own bone and carti- 
lage will definitely require new comput- 
er-assisted tools and improved surgical 
techniques," DiGioia says. "This is an 
example of a goal that would have been 
regarded as impossible not long ago, but 
is now within the reahn of the attain- 
able, all to the benefit of our patients." ■ 



"Specialties within medicine do have dis 
tinct subcultures about touch," Candib 
says, "all the way from the proscriptions 
against touch in psychiatry to the man 
date for touch in neonatal care." But, she 
adds, such subcultures reveal only a small 
part of what she sees primarily as an edu 
cational issue that raises overlapping 
questions of culture, training, and, espe- 
cially, power. While physician educators 
have largely neglected these issues. Can 
dib adds, the nursing profession has not. 

Nurses have studied the impact of 
touch on patients in newborn nurseries, 
labor and deli\'ery units, intensix'e care 
units, psychiatric units, chronic care set- 
tings for the elderly, and oncology wards. 
They ha\'e studied how patients respond 
to touch physiologically and have inter- 
viewed patients and each other about the 
effect of touch, including asking patients 
and colleagues to comment on \ideotapes 
of moments of nurses touching patients. 
"Underlying all this work," Candib says, 
"is the belief that touching is an essential 
component in the heahng process." 

By contrast, Candib says, "During the 
past 30 years, concerns about touch b\' 
physicians have re\'olved primarily around 
allegations of sexual abuse and mal 
practice issues. For the most part, med 
ical training still does not address touch 




f 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 25 



directly, except possibly in courses on 
physical diagnosis or end of life care. 1 
doubt that medical students receive any 
consistent message except the explicit 
one — that the only purpose of touching 
the patient is to glean information Irom 
the examination — and the unspoken 
message that touch is dangerous." 

A Touchy Subject 

Despite the barriers to touch that exist, 
says Candib, caring physicians do 
manage to incorporate touch into their 
interactions with patients and not just 
as part of the cUnical exam. "Most of 
these doctors feel that how they touch 
patients is crucial, whether it is part of 
the exam or apart from it. Palpating is 
the kind of touch that doctors expect to 
do, and it may be the only form that 
patients receive; of great importance is 
actually how we palpate — firmly, gently, 
thoroughly, briskly, tentatively — all 
convey meaning to the patient. Many 
doctors use a steadying hand on the 
patient's right shoulder during the car- 
diac exam. It establishes physical prox- 
imity, a counter- touch to the stetho- 



scope. It also sets boundaries by main 
taining a certain distance, defines the 
activity as nonsexual, and allows the 
doctor to gauge the distance between 
his or her trunk and the patient's body. 
And for some doctors it is a way of 
establishing connection." 

Yet, Candib adds, physicians general- 
ly need to be more cognizant of what 
she perceives as the huge power imbal- 
ance that typically exists between doc- 
tors and their patients. "Clinically 
appropriate touch is a double-edged 
phenomenon," she says. "It can repre- 
sent a powerful form of positive human 
interaction, but it also carries the poten- 
tial to be abusive, sometimes in the 
hands of physicians who aren't even 
aware that their touch is of an abusive 
nature." The potential for misunder- 
standings of the effective use of clinical- 
ly appropriate touch, she adds, has only 
grown in the past decade, during 
which, she says, "medicine's attention 
has increasingly focused on randomized 
clinical trials as the gold standard of 
high-quality evidence." 

This increasing emphasis on clinical 
trials has led to widespread question- 




ing of the purpose and utility of the 
traditional physical exam, Candib says. 
She speculates that such a devaluing of 
the physical exam may account, at least 
in part, for the increasing numbers of 
patients seeking care from alternative 
and complementary practitioners who 
focus on touch- centered therapies. 

"Americans now spend billions of 
dollars out of pocket for someone to 
touch them in ways they perceive as 
healing and non- abusive," she says. 
"Contrary to what some in the profes- 
sion behe\e to be the decreasing rele- 
vance of the physical exam, the popular- 
ity of these complementary approaches 
with the American pubUc suggests that 
people seeking care do indeed \'alue the 
element of touch in clinical encounters." 

The discrediting of the physical 
exam, Candib beUeves, has also led, in 
turn, to a deterioration of clinical skills 
on the part of young physicians and 
medical students. Part of the problem, 
she says, is that the art of the physical 
exam is typically taught in a highly 
decentralized manner. The medical stu- 
dent rotates through different settings, 
learning to do an eye exam here and an 
ear exam there, without ever being 
taught a coherent, overarching philoso- 
phy of the physical exam and the role of 
touch in the clinical encounter. 

The discrediting of the physical exam 
also reflects the advent of new diagnos- 
tic technologies, some of which have 
profouncOy altered the role of touch in 
clinical practice. "When I was training," 
Candib says, "everyone was schooled in 
the subtleties of how to listen for a heart 
murmur and how to analyze lung 
sounds. But today a physician who sus- 
pects the presence of a murmur in a 
patient will just order up an echocardio- 
gram. The feel of a spleen, or the size of 
a Uver, just doesn't receive the same level 
of attention it once did. Perhaps the only 
area where a premium is still placed on 
old-fashioned physical diagnosis is in 
the detection — in conjunction with 
mammography — of a breast mass." 

Although she welcomes the use of 
technological aids that enhance patient 
care, Candib is troubled that physicians 
today are doing fewer and less thorough 
physical exams. She also expresses 
reservations about the ripple effect 
technology has had on attitudes toward 
the overall importance of clinical touch. 



26 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



f 
any doctors use a steadying hand on the patient's 

right shoulder during the cardiac exam. It estabHshes 

1 Hi 1 . . 1 . .1 . .1 



"I was taught, for example," she says, 
"always to place my stethoscope direct- 
ly on a patient's skin. Nowadays, it's not 
uncommon to see students place their 
instruments on top of the patient's gar 
ment." Whether they do this out of 
convenience, modesty, or sheer lazi- 
ness, Candib says, "they convey the 
notion that the results don't really mat 
ter — nor do the patient's expectations." 

Nonetheless, Candib readily con- 
cedes that, in some respects, the shift 
in emphasis has benefited patients. 
"Many physicians today won't bother 
to do a rectal exam as part of the physi 
cal exam. When I was in medical 
school, it was unthinkable for a patient 
to be admitted to a hospital without 
undergoing a rectal exam. In fact, the 
poor patient might even have to submit 
to three such exams, when, I think it's 
fair to say, one really is enough." 

A Class of Touch 



Another key factor driving the chang 
ing role of clinical touch, Candib 
believes, is the loaded nature of touch 
in an age of great vigilance about abuse. 
Physicians must take factors such as a 
patient's age and psychological condi- 
tion skillfully into account. "If the 
patient is a two year old, say, or a para- 
noid schizophrenic, it's crucial to give 
that patient space," she explains. "And 
teenagers require a great deal of non- 
verbal respect for their body integrity." 
Like many of her colleagues, Candib 
has developed a nuanced, personal style 
of clinical touch: "I generally like to 
start out an exam on a very young child 
by touching that child's shoe to gauge 
how close I can get," she says. "I will 
also tickle a baby's toes before I touch 
the baby's torso. For me, it's a process 
of respecting the patient's physical 
integrity and gaining their gradual 



approval in a way that makes the exam 
seem less cold, scary, and invasive than 
it might have if I had simply forged 
ahead without taking the time to create 
a permission based exam." 

But, not having been taught much 
about the prescriptions for as well as 
proscriptions against clinical touch, 
many physicians do not feel comfortable 
with such strategies, Candib acknowl- 
edges. Sometimes, she says, a physician's 
aversion to touch can even border on 
what she would describe as extreme. 

"Some doctors actually fear touching 
their patients," she says. "I once had a 
patient with AIDS who was suffering 
from a difficult- to-diagnose skin rash 
and seizures. I sent her to a neurologist, 
who insisted on donning a full gown, 
mask, and glo\'es before examining her. 
The message to the patient was: you are 
unacceptably contaminated. Of course, 
I believe in standard, reasonable pre- 
cautions such as thorough hand wash- 
ing and the wearing of gloves, but we 
have to think about what signals w^e are 
conveying to sick patients when — and 
how — we touch or do not touch them." 

Given the rapid pace at which tech^ 
nology is transforming all aspects of 
medicine from the examining room to 
the operating suite and beyond, Candib 
believes that it is crucial for medicine 
both to reaffirm the primacy of touch 
in healing and to teach future doctors 
a coherent philosophy of clinical touch. 
Complementary approaches may have 
something to teach mainstream medi- 
cine in this regard, she says. 

Candib began thinking about what 
she describes as a "directness of touch" 
characteristic of many complementary 
disciphnes when she sought out mas- 
sage therapy to ease headaches she was 
suffering as a result of muscle tension in 
her upper back and neck. Based in part 
on this experience, she started an out 



reach program aimed at providing mas- 
sage treatments to Southeast Asian 
immigrants debUitated by chronic pain. 

"I was really struck," she recalls, 
"by how much attention is paid to the 
topic of appropriate clinical touch in 
the training of reputable alternative 
practitioners. The result is that such 
practitioners can go a lot further in 
terms ol touch and still be respcctlul 
of their patients and maintain excel- 
lent professional distance. Nobody 
learns such protocols in medical 
school, although many good clinicians 
do, over time, develop their own per- 
sonal styles." It would be helpful 
indeed, Candib says, to doctors and 
patients alike, if medical education 
formally advocated consistent, coher- 
ent philosophies of clinical touch. 

But how, she asks, can physicians 
acquire such a philosophy when they 
learn that only task-related touch such 
as palpation is acceptable? "By not 
touching in any other way," Candib 
says, "we feel free to become uncon- 
scious about touch, and indeed we are 
often unaware of our nonverbal behav 
ior, perhaps because we are tuning in so 
hard to verbal communication, both in 
form and content. To a great extent 
\\'hat we do with our hands has become 
unconscious, sometimes mindless, 
sometimes thoughtless. From such 
unconscious acts, poor communication 
and misinterpretation are born." 

To avoid such misinterpretations, 
Candib suggests, "we need to rethink 
the role of touch in clinical care and 
resist the notion that the clinical exam 
can be discarded. And we need to refo- 
cus on the idea that respectful human 
presence and touch are central to clin 
ical work." ■ 

Beverly Ballaw is associate editor of the 
Harvard Medical Alumni Bulletin. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 






m>^m^mmifMm^M&''j:i-. 





m 




OF TOUCH IN HEALING 




A physician reflects on the 
centrality of touch in making patients 
better — and in making better doctors 

by Michael A. LaCombe 



AN INTANGIBLE ART 




ONG AGO AND IN ANOTHER AGE, EACH 

summer before beginning work at the paper mill, I would visit the 
office of our border town s general practitioner for the mandatory 
physical examination. For a boy of 19, this ritual was a mix of 
bother and beginning: the former for obvious reasons and the lat- 
ter because it marked the start of a new summer on the ri\'er, with 
no papers due, no all-nighters, no Saturdays in the stacks — ^just 
cash on hand and new student nurses rotating through the local 
psychiatric hospital, wanting to dance and drink beer. With these 
coming distractions, I could be just peripherally aware of the doc- 
tor and his office, calhng it up only decades later when it would 
surface in my memory as a black-and-white fUm from the fifties. 



Year after year, he would begin his exam 
with the same request: "Let me see your 
hands." And while he peered at them, 
and at my fingernails, looking for God 
knows what, I could in those moments 
steal a look around the room, which 
was, of course, in his home. There was 
the obhgatory skeleton supported by a 
stand, on which a white lab coat hung 
as well. In a corner, the exam table 
stood partially hidden by a freestanding 
fabric screen. Pinned to the opposite 
wall, a yellowed, dust covered chart, its 
corners curled, displayed four \iews of 
what I guessed was the heart. On top of 



an equally dusty bookcase, sho\'ed full 
of books in random disarray, his medical 
school diploma leaned against the wall. 

"Hopkins," I said softly. 

"The best in my day," said the G.P. 

"Harvard is now, right?" I asked. 

"They think so," he said. He motioned 
me over to the exam table, listened to 
my chest, had me grunt and bear down 
while he listened, made mc stand and 
squat and listened again, then had me 
lie on my left side — and listened some 
more. It would be 30 years before I 
would know what these maneuvers 
indicated about him. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



29 



"Why are you doing this?" I asked, 
emboldened by the intimacy o[ the 
moment. 

"Putting you on your side like this?" 
he replied. 

"No, I mean why are you here instead 
of somewhere else?" I asked. "After Hop 
kins.. .you could be in Syracuse or Albany 
or New York City even, couldn't you?" 

"The river," he explained. 

"They've got rivers too," I said. 

"Yeah," he said, "they do. But here I 
have the best chance to know my 
patients." 

He left me with that legacy, one 
of getting close to patients, touching 
them, examining them, snatching 
glimpses into their souls. 

Forty years later I've managed to 
hold to the notion that touching 
patients is vitally important. Patients 
expect you to touch them, for one 
thing, and when you bother to do so, 
they feel closer to you, and they 
become aware that you care. I believe 
they do better because of it. Maybe 
they trust you, and so take your advice 
and your pills, and call you when 
they're supposed to. Maybe that's why. 
And besides, proximity promotes chat. 
We called it taking a history. 

But now there are forces to the con- 
trary: the contracted time allowed wdth 
patients; the consuming belief in tech- 
nology to the exclusion of intimacy 
with patients; and, sadly, the loss of 
trust in the art of medicine. It makes 
you either want to give it up, or search 
for some hard c\'idence that touching 
patients might still be a good thing. 

So I left my practice in Augusta, 
Maine, to travel to one of the big hospi 
tals to the south with the official pur- 
pose of acquiring a month's worth of 
education. I didn't admit that I was 
really looking for some hard evidence to 
prove something to myself. 

Coming from the country, I found 
plenty of distractions. The hospital 
lobby alone had more people than in my 
entire hometown. And everyone under 
the age of 40 wore pajamas. But I found 
some important-looking senior men, 
clad in bowties and long white coats 
buttoned to the floor, who led grand 
parades here and there throughout the 
hospital. The bowties led me to my first 
breakthrough. You see, I knew from 
medical historv that the bowtic had 



come into fashion shortly after the 
stethoscope, that clinicians wore 
bowties so that, when leaning over a 
patient to catch the paradoxical split, 
the necktie never got in the way. 1 
attached myself to one of the entourages 
to watch them touch patients and gath- 
er my data. 

It didn't work. The entourages never 
seemed to reach anyone's bedside. Even 
when headed in that direction, they 
would stop in the hall, or in the door- 
way, and ne\'er actually make it there. 
And no one seemed to touch a patient. 
Usually, the groups avoided patient 
care areas altogether, heading to radiol 
ogy instead, or to the echo lab. Here the 
drill was always the same. The bowtied 
professor would stand quietly at the 
head of the entourage and wait to be 
noticed. Suddenly everyone would 
freeze, as though someone had punched 
the "pause" button on the remote. The 
professor would ask to be shown "an 
image." Techs would scurry to do his 
bidding. Then the professor would 
expound on minutiae that had nothing 
to do with touching patients. 

I could sense the fear in the students, 
residents, and fellows huddled in the 
back of the room with me as they wait- 
ed to be embarrassed by some impossi- 
ble question about metalloproteinases 
and vascular biology. There were no 
patients there, mind you. No need for 
them. And that in a way was a relief — 
the presumed ignorance of these young 
doctors would ne\'er be re\'ealed to the 
discomfort of their patients. 

My research was going nowhere. 
And I was beginning to doubt myself — 
always a bad thing when you're 60. So I 
hatched another plan. I volunteered to 
learn a medical technique — trans 
esophageal echocardiography, which 
im'oK'ed wheeling a large echo machine 
all over the hospital, washing the 
machine parts in various solutions sev- 
eral times a day, and filling out papers 
and forms. It was the perfect ruse. 
Everyone assumed I was an old man, 
stuck in a menial job, who hadn't fig 
urcd out where they kept the pajamas. 

They must have thought I didn't 
speak English either, because they 
talked freely in front of me, sometimes 
about cases and patients, but mostly 
about their jobs and their professors. So 
I watched and listened and kept my 




mouth shut and wrote it all down. xAnd 
no one except the most junior of nurses 
even noticed me, or helped me with the 
papers, or held the door for that big 
machine I was wheeling around. I kept 
my head down, obsequious and defer- 
ential. Here's what I learned: 

• that the professors were disinclined 
to teach the young doctors, or were 
always in their labs doing meaning- 
ful research, or away on "visits," or 
just didn't seem to care; 

• that when there was a potential 
teaching moment, the young doc- 
tors were made to feel stupid; 

• that with so many patients to attend 
to, and so much paperwork and 
charting and clerical work, the young 
doctors began to resent patients, 
\iev\ing them largely as a burden; 

• that the young doctors spent pre- 
cious little time together and hardly 
knew each other; 

• that they knew e\'en less about their 
professors, or what their professors 
believed, what they held important, 
what made them laugh, what frus- 
trated them, why they were there, 
and what sort of life they thought 
might be best to lead; 

• that the young doctors had come to 
believe that imaging was the impor 
tant thing, that talking to patients 
and touching them was passe, just a 
footnote in history; and 

• that because of this experience, they 
loathed the place, couldn't wait to 
leave, and didn't mind telling this to 
any applicant coming through. 
Imagine my distress. Here in this 

place I had held most dear, in this grand 



30 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



was me peneci ruse. iLveryone assumea i was 
I old man, stuck in a menial job, who hadn't 
igured out where they kept the pajamas. 



hospitd with a French restaurant right 
in the lobby where people bought cups 
of steam anytime they wanted, there 
existed this much unhappiness. Here — 
where I now ran up exorbitant hotel 
bills just for the chance to be among 
these doctors and ate congealed 
spaghetti at a galleria to keep expenses 
down — were young people getting paid 
to learn, yet hating the experience, 
marking the days like Edmond Dantes 
in the Chateau d'If. That happiness 
might be found in touching patients 
was not a message left to me to impart. 
Who was I after all, but an elderly tech 
nician wheeling a cumbersome machine 
from floor to floor? 

Nor could I publish this. This 
would be viewed as soft stuff. I had no 
data, nor even a cohort. The bowtied 
professors would discount any paper 
of mine as mere recreational reading. I 
had only a week left, and my research 
was going nowhere. 

And then I found her. She was sitting 
m a solarium up on the 12th floor with a 
student, talking quietly. I positioned my 
echo machine so that I could watch 
them discreetly and pretended to enter 
data onto the tape, adjusted knobs I had 
been told not to touch, and observed. 
The student was listening intently, nod- 
ding his head occasionally, hanging 
upon her every word. They went on in 
this way for some 20 minutes. And then 
1 obser\ed a peculiar thing. The profes 
sor leaned forward, reached out, and 
touched the student, taking his hand! 
He nodded his thanks, got up to lea\'e, 
turned and smiled at the professor, and 
headed for the ele\-ator. I wheeled my 
machine into the elevator after him. 

"Excuse me," I said, "but I'm doing a 
study, establishing a cohort and so forth, 
and making obserwations. Would you 
mind telling me a httle about the meet 
ing you just had with your professor?" 



The student stared at me with 
traces of shock and fear, as though I 
had somehow escaped from a neigh 
boring hospital. He got off at the next 
floor. I couldn't really blame him. I had 
traces of green slime on my coat from 
washing machine parts. And I didn't 
have a bowtie. 

But now^ luck was with me. A few 
days later, I went to the French restau 
rant in the lobby and there she was! The 
same professor! Sitting alone at a table 
in the back, with no one around. What 
did I have to lose? I was lea\'ing in the 
morning anyway. 

"Mind if I join you?" I asked. 

"Not at all. Please do." 

Silence. 

"You teach here?" I asked. 

She smiled, squinting at me with her 
blue eyes, then brushed back her gray 
ing hair. "You ha\'e something on your 
mind," she said. 

"I do?" 

"Wt're surrounded by empty tables. 
You sat here for a reason. Am I right?" 

A diagnostician, I thought. 

"I saw you sitting with that student 
the other day..." I said. 

"I sit with a lot of students," she said. 

"You do?" 

"It's my job." 

"It didn't seem like a job," I said. I 
was getting bolder. She seemed to 
engender that in a person. 

"Yes, I teach here," she said. "And I 
love it. So it probably doesn't seem like 
a job to an observer." 

"That's what I am. I'm an observer." 

"I see," she said. I was in danger of 
being returned to a neighboring hospi 
tal, so I hastened to continue. 

"What I mean is, I came down here 
to get some proof that touching 
patients matters, that it's still a good 
thing to do. I'm a doctor too, but from 
the country up north. I see patients all 



day. Not like this. Not like you. Rut 1 
love it. Like you do your students..." 

"How perfectly noble," she said, 
interrupting. And I knew she meant it. 
She continued. "Well here, the stu- 
dents — and the residents and fellows — 
are my patients, if you can think of it 
that way. I touch them. Oh, not physi 
cally. I don't mean that. But I try to 
touch every one of them. I want to 
know who they are, and what makes 
them happy, and where they're headed. 1 
want to share part ol myself, so they can 
see I'm human too. 

"I think it's important for their edu- 
cation to see me as a human being, as 
someone who cares, and who cares 
about them. That's touching them, you 
see. It's my hope they'll carry that away 
with them, remember it, value it, make 
it a part of their lives, and pass it on to 
their students. That's the tradition of 
teaching, after all." 

"I envy you." 

"Well, don't," she said. "We both do 
the same thing. My students are my 
patients; your patients are your stu 
dents. It sounds as though you touch 
them and teach them. And you're right. 
Touching is important — the most 
important part of being a doctor, or a 
teacher. You can quote me on that." 

She stood, held out her hand to take 
mine, then took my hand in both of 
hers and wished me luck. 

Let mc sec your hands, I remembered my 
old G.P. saying to me 40 years earlier. 

I left for home the next day with 
this N of one, hardly a cohort, but with 
data enough to satisfy me. And I left 
with the hope of someday publishing a 
study that might change, if not the 
world, then some certain place I hold 
most dear. ■ 

Michael A. LaCombc '68 is director of cardi- 
ology at the Maine General Medical Center 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



31 





t 




OF TOUCH IN HEALING 



An internist scrutinizes her patients' hands to 

uncover clues to their physical and emotional 

well-being by SuSANNA BeDELL 




OCTOR B., A PATIENT NEW TO MY PRACTICE, 

arrived punctually at nine in the morning, impeccably dressed in 
a white starched shirt and flowery Ferragamo tie. He was a 50- 
year-old neurosurgeon who wanted a "thorough checkup." His 
history showed that he was a healthy, avid jogger, and his only 
hospitalization had been for a kidney stone several years ago. 



An examination of his hands revealed 
perfectly sculpted nails and warm, 
smooth skin. The only ahnormahty was 
a faint indentation on the medial aspect 
of the left thumb. As I held his hand and 
ran my index finger over this smooth val 
ley, he became very quiet. It was undeni 
able — this perfect pair of hands bore one 



sure flaw. 1 gently probed him for infor 
mation, referring to patients in general 
who rub their fingers together, almost 
like a rubbing stone, to reheve anxiety. 
My inquiry triggered an hour-long 
outpouring about the overwhelming 
stress in my patient's life, stemming 
from a potpourri of causes ranging from 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



raTraasrssnimii 



palmar vessels compressed and dilated. Suddenly 



managed care pressures at work to a 
wild adolescent at home. Dr. B. con- 
fessed that he used the corner of his 
blanket each night to rub his thumb 
and dull his anxiety, thus lulling him 
self to sleep. This deep secret, he con- 
fided, was one he had shared only 
\\'ith his wife. 

This defining moment with Dr. B. 
changed what might have otherwise 
been a routine nsit to one with ultimate 
therapeutic benefit. It may sound like 
an odd encounter, but \'ariations on this 
theme are commonplace when medical 
practice includes touching, examining, 
and pausing over a patient's hands. 

A Show of Hands 



During my patients' visits, I have three 
occasions to touch their hands: the 
salutary handshake, my examination 
of their hands, and the parting hand- 
shake. All three have the potential to 
transform our encounter. 

Just as hosts welcome guests with a 
handshake, physicians greet patients 
with an outstretched hand to assure 
them that they are welcome, and not a 
burden in a busy day. A sincere hand- 
shake conveys empathy and warmth. 
Doctors who offer a hand are also more 
likely to take the time to listen careful 
ly Those who feel they dorit have time 
to shake hands may well be competent 
clinicians, but they are signaUng that 
they probably won't be inclined to 
attend to the patient's emotional needs 
or to offer the hope and compassion 
that may prove to be hfesaving. 

This initial handshake can also 
provide the doctor with hints about a 
patient's illness, character, or psycho 
logic state. Is the patient's palm warm 
and moist, suggesting hyperthyroidism 



or anxiety? Does the patient pause in 
the process of shaking hands to greet 
the doctor with enthusiasm and confi- 
dence? Or does the patient's grip feel 
limp? Does the patient pull his hand 
back before the greeting is even com- 
plete? Such a gesture may not yield an 
actual diagnosis, but it does suggest 
that the patient is insecure, ambiva- 
lent, or anxious about \i,siting a doctor. 

The Art of Palm Reading 

The marvel and mystery of the human 
hand first caught my attention when I 
worked in a small, dusty pottery stu 
dio in Berkeley, California, the year 
after graduating from college. When 
not sweeping the floor or studying for 
my premcd classes, I watched potters 
magically transforming mounds of clay 
into beautiful objects. Subtle changes 
in the pressure of these skilled hands 
affected the clay enormously, and the 
shapes, variation, and power of the 
human hand captured my imagination. 

Early in my practice in rural Texas, I 
began observing my patients' hands 
out of curiosity. The hands of those 
Texas farmers differed from those I had 
encountered during my training in 
Boston. They were large, strong hands 
that had recorded life stories through 
signs of wear and tear on every crevice, 
knuckle, and palm. Visibly muscled, 
they reminded me of a potter's hands. 
.And I began to observe subtle differ 
ences among my patients" hands, 
which had, at first, looked alike. 

One patient, Mr. C, was a farmer 
who paid for his \isits with the biggest, 
freshest, sweetest tomatoes I ha\e e\er 
tasted. He was a quiet, gentle man 
whose warmth and enthusiasm soon 
made him a fa\'orite at the office. One 



day when holding his hands to look for 
new calluses, I noticed that he had 
developed clubbing, a soft tissue 
swelling at the fingertips that can be 
associated with an underl)ing iLLness, 
such as cardiovascular disease or lung 
cancer. A chest x-ray that day re\'ealed 
a small pulmonary nodule, a cancer 
that was small enough to be removed 
and cured with surgery. 

Since that encounter with Mr. C, I 
hax'c always begun each physical by 
taking my patients' hands in my owti 
and stud)ing them closely, both for 
diagnostic and therapeutic benefit. I've 
found that changes in the hands or nails 
offer in\'aluable clues to underhing dis- 
ease in all organ systems. Thickened 
tendons in the palms, for example, may 
be indicati\'e of diabetes. Painful lumps 
in the fingertips are sometimes associ- 
ated with infection of the heart valves. 
And paUor with scooping of the nail 
bed suggests iron deficiency anemia. 

Proliferation of tiny vessels at the 
base of the cuticle may develop in such 
rheumatologic diseases as systemic 
lupus. Whitening of the base of the nail 
can occur in cirrhosis of the liver, and 
longitudinal striations offer a subtle 
clue to hyperparathyroidism, an endo 
crine disease that causes hv'pcrcdcemia 
if untreated. And palmar erythema — 
pink palms — may be a sign of alco- 
hohsm or another cause of hver disease. 

I once had a patient — an elderly, 
proper Bostonian woman — with a 
history of chronic burning in her 
abdomen. She adamantly denied drink- 
ing alcohol, yet nothing in her story 
could explain the origin of her pain. 
When I examined her pale hands, I 
found her palms warm and pink. As I 
pressed on the fleshy pink of her hand, 
feeling a mixture of curiosit)' and com- 



34 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 




passion, the palmar \-cssels compressed 
and dilated. Suddenly warm teardrops 
began to fall on our hands. She met my 
gaze and murmured, "You know, don't 
you?" This woman, married to a power- 
ful and abusive man, had started drink- 
ing in secret to reUevc her anxiety, and 
her hands betrayed the stigmata of 
chronic Uver disease. 

The compassionate taking of the 
hand not only enlarges medical histo 
ties, but can also help to minimize the 
shame that many patients feel about 
a history of depression or substance 
abuse. Ms. D. was a young woman 
who, years earlier, had struggled with 
a suicide attempt that had left scars 
on her wrist. She had been seen by 
many physicians and was skilled at 
maintaining a formal, reserved, dis- 
tant posture. Talking with her 
reminded me of what it was like to 
piece together my adolescent son's 
monosyllabic responses when he was 
asked about his day at school. 

After observing Ms. D.'s scars, I 
paused and ran my index finger gently 
over them in quiet recognition of what 
she had endured. We did not exchange 
words at that moment, but her eyes 
told me that this simple act had dissi- 
pated her impenetrable fagade. 

At times a diagnostic ob.ser\'ation 
about the hands can be linked to ther- 
apeutic effect. One middle aged poet 
with prominent ridges on her nails 
told me that she always tried to hide 
her hands, because she felt ashamed of 
them. What I saw, though, were ele- 



gant, powerful hands with mus 
cles around the right thumb well 
developed after years of writing. 
My immediate association was 
with Georgia O'Keefe's stat- 
uesque hands, as photographed 
by her husband, Alfred Steiglitz. 
Sharing an analogy to an artist 
undoubtedly altered this woman's 
impression of her hands and perhaps, 
in some sense, of herself. 

Taking a patient's hands is more 
than a simple rituaUstic act: it estab- 
lishes a moment in which the doctor 
can achieve an active, undistracted 
concentration on the patient. This act 
can become a safe point at which the 
doctor can pause, establish an inquir- 
ing mindset, and experience the 
focused, critical self-reflection often 
referred to as mindhilness. Because 
everything they have to reveal is evi- 
dent by simple observation, the hands 
offer a unique opportunity for the 
physician to become totally engaged 
with the patient and his state of mind. 
The therapeutic value of looking at 
the hands derives not only from the 
diagnostic insights it provides, but 
also from the power of touch. Espe- 
cially in this era when touch often has 
a bad name, and medical evaluation 
has become increasingly technologi- 
cal, taking the patient's hands 
assumes an even greater significance. 
A thorough physical exam involves 
touching the patient in intimate ways. 
Sitting knee to knee and taking the 
patient's hands is a nonthreatening 
way to establish physical contact. 

Unlike other aspects of the physi- 
cal exam, which may take the form of 
poking or prodding, examining the 
hands requires holding them. I like to 
hold one hand at a time, explore its 



details, turn it o\'cr, and gently return 
it to the patient's lap. As the evalua- 
tion progresses, I can feel the hand — 
and the patient — relax. 

Such a lending of the hand is a way 
to estabhsh the connection that both 
doctor and patient crave, as well as a 
means to empower patients as engaged 
participants in their care. Taking the 
hand is a nom'crbal, nonsexual, non- 
threatening way for physicians to reas- 
sure patients, "1 will take care of you." 

The final taking of the hands is the 
parting handshake. This farewell 
clearly delineates the end of the meet- 
ing and reinforces the positive rela- 
tionship that both doctors and 
patients seek. It allows patients like 
Dr. B. or Ms. D. to look the doctor in 
the eye and to be reassured that no 
matter what has occurred during the 
office visit, no matter how vulnerable 
they have felt, the doctor has under- 
stood, valued, and respected them. 

The rhetoric of cost-effective med- 
ical management is often counterbal- 
anced by pleas for caring. How do 
we translate these well-intentioned 
words into action? What specific 
guidelines can we give our students 
and ourselves to heal the depersonal- 
ized relationship between physicians 
and patients? Careful examination of 
the hands may be a route to this end. 
It is one means to pause with the 
patient, thus emphasizing that the 
humanistic aspects of attention, 
touch, and personal history are as 
important as the scientific or quanti- 
tative elements of medicine. ■ 

Susanna Bedell 77 is an assistant professor 
of medicine at Harvard Medical School and 
an internist and director of the Diabetes 
Clinic at the Lown Cardiovascular Center 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



35 



A physician reflects on the intersection of flesh, spirit, and steel 



I 



i 



I 



by Ray B ABINEAU Radiation begins today. 

An earlier surgical effort to remove my prostate 

cancer had met with only partial success, as the 

growth had already escaped the surgeon's reach. 

I The operation had been quick, three hours of 

i unconsciousness. Now we try another tactic: 

i radiation for two months, five days a week. Plenty 

i of time to be fully conscious as I do my time under » 





WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



In medical school, I had been taught to fear the force of 



the machine. I yearn for the eradication of my cancer, 
but a statistician would say it looks dicey. 

I drive daily to the cancer center. During my own med- 
ical training, the word "cancer" never appeared on any 
buUding, but now I find it emblazoned near the entrance. 

Separated from the unplanned sprawl of the medical 
complex, the cancer center affords pri\'ate parking for its 
patients. Inside, the staff members are unusually friend- 
ly; I suspect they've been preselected to work here. The 
atmosphere is pleasant, the way a hospital should be but 
usually isn't. Then I remember that to receive all this 
tender loving care, you have to hold a specific admission 
credential, and I've got it. 

I descend in the elevator 
from the ground floor to the 
basement, a location dictated 
by the sheer tonnage of these 
high-tech machines and their 
shielding. My own treatment 
room is dominated by a Unear 
accelerator, which requires the 
ceiling and walls to be lined 
with lead three feet thick. 

First, a short stay in the 
waiting room, which has been 
thoughtfully furnished with 
comfortable seats, a lounge 
chair for patients undergoing 
chemotherapy, and an over- 
stuffed rocking chair as 
inviting as a grandmother's 
lap. Bright orange fish peer at me unblinking from 
inside their large tank. 

On my first visit I discover the etiquette here: we all 
say hello to each other, regardless of whether we have 
met before. Instant equality and camaraderie. It is 
forced, yet real. Two retired construction workers dis- 
cover they worked for rival companies. Soon enough, 
matching acquaintances emerge: "You knew Larry 
Welch? He was such a great guy!" I notice "was," with a 
new sensitivity to the use of the past tense. Mortalit)- 
and fear are the great levelers in this waiting room. 

My turn arrives, and I enter the chamber to meet my 
machine. It is immense, cool, and white. The business 
end of the linear accelerator rides on a gigantic arm that 
rotates 360 degrees around the treatment table. It looks 
like something out of the film 2001: A Space Odyssey, 




I step into the empty 
compartment and push 
the button. It's then I 
notice the manufacturer's 
nameplate: "Schindler: 
Capacity 4500." I hope 
I'm on his good list. 



which seems fitting since it's 2001 and here I am, about 
to embark on my own journey into the unknown. 

The radiation technologist instructs me to lie on the 
table. She places a to\\'el across my groin and asks me to 
raise my shirt and lower my pants and under\\-ear. To 
minimize movement, she binds my feet together and 
folds my arms across my chest to remove them from the 
radiation field. I He there in my loincloth, staring at the 
ceihng. Directly abo\'e me, cut into the ceihng tile, I see a 
crude set of lines resembling a cross. A second cross, this 
one laser-Ughted, shines through the first to mark the 
spot that will align my position on the table with the 
eight precise dots that are tattooed onto the skin of my 
abdomen, almost like the grid for a ticktacktoe game. 
The ceihng cross reminds me of the countless times in 
childhood when I stared at a crucifix. It feels Kke a big 
"gotcha, at last!" Or in any case, the lottery of biolog)'. 

Across the room I see a row of head masks neatly 
aligned on a shelf. Each one is made of a wide plastic 
mesh that has been hardened around a patient's face 
in preparation for radiation. The masks are carefully 
labeled with names. (You don't want mistakes here: 
wrong head, wrong treatment.) One of the masks has 
the nose portion trimmed away. Big nose? Claustro 
phobia? Irradiation of the brain requires complete 
stillness. I have seen these folks in the waiting room — 
their tattoos are on their heads, newly bald. No hiding 
for them. I wonder whether they get to keep their 
masks as souvenirs. And I remember an image I had 
seen in childhood of a monk at his study table, with a 
book, a candle, and a human skull sitting to the side. 
Daily he is obligated to take the skull into his hand 
and contemplate his own mortality. 

To my right is a computer screen simply stating my 
name and hospital number. Below are listed rows of 
numerical coordinates of my pelvis. I had expected 
something jazzier, a colored, three-dimensional \'irtu- 
al reconstruction. I had even toyed with the idea of 
using it as a holiday card for family and friends. But no, 
ju,st naked numbers. 

The technologist flashes me an obligatory snule and 
pronounces everything "A- okay" for the treatment to 
begin. She scuttles out of the room to take refuge 
behind the shielded wall: not even a small window 
there, just a telexision monitor and a PA system. I 
understand why my cancer has to be here, but why me? 
.\nd then I remember our intimate attachment. 



38 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



radiation, but now I must give it a grudging acceptance. 




WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 39 



'It's an interesting thing, Ed. I am trying to find ways to 



Motors begin to whirl faster and faster inside the hn 
ear accelerator, speeding up the photons that will be 
hurled right through me. A large green sign begins to 
blink steadily: "Ready." Ready or not, here it comes. The 
technologist instructs me over the PA system, "Breathe 
normally now" A red sign glares: "Beam On." 

The treatment lasts only a few minutes and is not 
discernible to me. Invisible forces are at work. I try to 
think positi\'e thoughts, to be a cheerleader for my own 
survival. The radiation targets cancer cells, but those 
cells are mingling promiscuously with normal cells. In 
medical school, I had been taught to fear the force of 
radiation, but now I must give it a grudging acceptance. 
New game, new rules. 

The whining motors fade and the technologist reap- 
pears from her safe grotto and ushers me courteously — 
but firmly — off the table as it descends. "No jumping, 
please," she cautions, revealing long experience with 
anxious patients all too eager to leave this lead cave. 
With buttons and zippers I reassemble myself and fol- 
low the technologist to the ele\'ators rising out of this 
basement of dense shielding, energy, and penetration. I 
step into the empty compartment and push the button. 
It's then I notice the manufacturer's nameplate: 
"Schindler: Capacity 4500." I hope I'm on his good list. 

Trading Places 

By the second week of treatment, the waiting-room 
faces I see at eight in the morning are familiar, an "old 
guys' club," most of us with prostate cancer. But today, 
there are new faces too. A woman walks in shyly, wear- 
ing a colorful bandana. She appears to be in her mid- 
thirties. She smiles briefly, then rummages through the 
magazines. Does she feel ashamed of her baldness? Is she 
resentful that cancer has smacked her at such a young 
age? Cancer, always untimely, is an indi\idual attack of 
bioterrorism. She picks up Reader's Digest and holds it 
close to her face, providing a shield of privacy, so easily 
stripped away here. Judging from the front co\er, I'd 
guess she is reading the article called "Hero of Health." 

Another new face; a biker, obese, bearded, with a 
tangled sprawl of unwashed hair, barely tamed into 
a ponytail. I'm sure he doesn't want to lose that 
plumage. From the back pocket of his jeans swings a 
heavy chain securing his wallet. That chain could be 



handy in a fight, 
and I wonder if he 
has to take it off 



■I ^ 

^^^^^^^^ I 3 has to take it 

I^BBi I i during treatments 

riH^^ I I Toughness doesn't 

^H? I provide much pro 

^^^ ^^^^ I' ^^ tection here, where 

^^^LJ^^^ks L^"^^^^ radiation can cause 

^^^^■i^^^H^^^^^^H helplessly. As 

^^^^Bj^^^H^^^^^^H he bends to 

pick up a magazine, 
he reveals the crease between his buttocks, a private 
cleavage. On his hairy arm a tattoo reads: "I'm in Hog 
Heaven on my Harley." Ah, heaven. 

Then I recognize someone I know, sitting in a corner 
chair, wearing his white coat and dangling uni\'ersity ID 
card, and filling out the initial questionnaires. A new kid 
on the block! He is also a physician and we have shared 
patients over the years. We're both in our sixties, when 
name recall has become spott); so we each mention our 
own names first, to a\'oid embarrassment, then proceed. 

"What are you in for, Ed?" 

"Prostate cancer. How about you, Ray'" 

"Same. Radiation and a few 
blockade. You?" 

"Same thing. The whole works. Trying to be sure." 

But we both look at each other, kno\\ing that noth- 
ing is sure. 

"It's an interesting thing, Ed. I am trying to find ways 
to incorporate the cancer into the rest of my life." 

"Yeah?" He pauses for an instant, then glances down 
ward and begins to underline his journal articles. 

The other patients in the waiting room seem puz 
zled. Two doctors — one in a white coat, one in ci\'ihan 
garb — here for cancer treatment. What's wrong here? 
Don't union rules prohibit physicians from crossing 
over, becoming scabs? Sadly, no. E\-en though we'\-e 
apprenticed ourselves to diseases for a lifetime, we 
must learn some of them from the inside out. 

Rays of Hope 

The radiation oncologist is a patient man, putting up 
with my requests for detailed information with great 
tolerance. Perhaps he's even pleased that someone 



months of androgen 



40 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



incorporate the cancer into the rest of my life. 



shows this much interest in his work — at least I tell 
myself that to avoid the fear that he might be irritated 
by so many questions. The difficult dance between doc 
tor and patient in which, underneath it all, the doctor 
pleads for confidence: "Just trust me on this and we can 
get on with it." With my questions, I scratch about for 
reassurances but disguise it all as pleas for information. 

I ask him about the plan for treatment and he unrolls 
what looks to me Kke a sheaf of blueprints. They are 
somewhat smaller than those for a house, but as he 
folds back each leaf, I realize that this is a computer 
simulation of my pelvis. MRI and CT scans have been 
combined and, by an invisible microtome, I have been 
shced and diced, one centimeter at a time, from my 
na\cl southward. At first I fee! gratified to have had my 
house mapped out in such colorful detail, but when 1 
see him marking the area where my cancer has spread, 
my pleasure dissipates. 

With the sharp lead of his number 2 pencil, the doc- 
tor then .sketches the zone where he will widen the 
field of radiation, hoping to eradicate the recurrent can- 
cer. I silently cheer the hopefulness of this aggressive 
attack on the target zone until he points out the risks: 
since the cancer adheres to the bowel, wider radiation 
will also damage the normal bowel wall and surround 
ing tissues. The good comes wrapped up with the bad. 

"Most Kkely, many of the side effects will diminish 
within a few months after the radiation has stopped, 
but" — here, in this litigious age, he pauses — "I have to 
mention that a certain percentage of men will ha\e 
long-term side effects." The major effects being some 
degree of damage to bowel or bladder, as well as to two 
precious ner\'es. A pain in the groin. 

Feeling discouraged, I don't ask for the numbers. 
Fm tired of statistics. For the past ten months I've 
been falling to the wrong side of the curves. I've been 
extraordinarily fortunate in my life, but now I feel like 
I'm on the ninth life of the lucky cat. I tell this to 
Charmaine, my wife, and she gi\es the kind of reply 
that has helped sustain me for more than 40 years: 
"Oh, I don't think so. At the very most the sixth!" With 
support like this, my old house might be standing for 
a while. I'm uncomfortable with words like "cure" or 
"survivor." We're all just delayers. 

My moods are sometimes dark, but at other times I'm 
so upbeat that I recognize signs of mania. I'd like to Hve 



and do a dance across the face of death. A Zorba the- 
Greek kind of thing. Especially now that I've had 
months to contemplate my disease and the threat of 
death, I find myself ambitiously planning all sorts of 
things. With the prognosis stretching out for at least 
some years, I have no excuses. No more vague procras- 
tination. If not now, when? Nor can I use the short 
timer's excuse of — "I've got to settle my affairs, couldn't 
possibly start anything new." 

Even my journal feels ambitious. Extravagant fan- 
tasies fhcker through. I imagine nonchalantly asking 
Charmaine, "Has the New Yorker called yet about my 
manuscript?" 

"Yes, and they were very sorry to say they have to 
turn it down because they've published a lot of death 
and-dying stuff lately." 

"Oh!" 

"And someone else has a prior claim on the Zorba- 
the-Greek, full- catastrophe trope." 

Damn. Disappointment sits on my head and trickles 
down. Well, I'll still write for myself and whomever I 
can con into reading about my experience. I will trea- 
sure the responses that do come back. My cancer has 
become a litmus test of relationships. "We can always 
talk about the weather," i say, my sarcasm the cutting 
edge of my rage. 

I reread parts of biographies about Freud's and Dar- 
win's struggles with severe illnesses. For 16 years, can- 
cer had painfully eroded Freud's palate, jaw, and cheek 
before it finally killed him. Following his return from 
around the world on the Bcagk, Darwin was besieged by 
a still- hard- to define somatopsychic monster that 
intermittently paralyzed him for months at a time with 
nausea, anxiety, and deep depression. This was fol- 
lowed by progressive cardiovascular disease. 

These guys did not withdraw to sit by the swimming 
pool. They went into high gear and did some of their 
best work before ine\itably succumbing. The observing 
part of my brain cautions: "You're making grandiose 
comparisons, my friend." The feisty part of me says: 
"You know how important it is to have heroes." 

So it goes. It's never lonely in my head. And it's time 
to get busy. ■ 

R(jv Babincau '63 is a professor of psychiatry at Strong Memorial 
Hospital in Rochester, New York. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



41 



'SPARE 



5 




p^RlNWS 



When Sparr's Drug Store closed its doors after nearly 70 years of serving HMS, it 



42 




THE LOUD THUMP WAS AUDIBLE EVEN ABOVE THE NOISY CLACKING OF 

the Green Line subway cars shuffling along the Huntington 
Avenue track. Pretending to glare at the mortified first-year 
medical student who had fumbled a boxed set of diagnos- 
tic instruments to the floor, Arthur Sparr jokingly insisted, 
"Hey, you drop it, you buy it!" With a wink, he quickly added 
an aside: "See how I treat my customers?" ■ In the 
bustle of selling off his inventory prior to the permanent 
closing of Sparr's Drug Store in the spring of 2002, the 
owner's trademark courtesy showed no signs of diminishing. 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 




marked the passing of a storied institutional relationship by BEVERLY BaLLARO 



It was the playful, friendly 
atmosphere of this small 
drugstore and lunch counter 
clinging to the edge of the 
School's campus that had 
kept HMS students stream- 
ing through its doors for 
nearly seven decades. 

Arthur Sparr's father, 
Joseph, got started in the drug 
store trade as a teenager when 
he went to work in his uncle's 
New York City pharmacy. In 



1933, Joseph moved to Boston 
and purchased property on 
the corner of Huntington and 
Longwood avenues, where he 
set up shop. 

Sparr's Drug Store quickly 
established itself as an indis- 
pensable point of refer- 
ence — both geographical and 
social — on the School's cam- 
pus. Even a disastrous 1949 
fire did not deter Sparr's 
from fulfilling its mission. 



Joseph moved the operation 
to temporary headquarters 
in a building next door and 
ran his business out of that 
cramped space while recon 
struction took place. A year 
later, Sparr's reopened the 
doors to its original location. 
The drug store would remain 
open for the next 52 years. 

Arthur began working in 
the store in 1943, just a few 
years before the fire that had » 



GENERATION Rx: 
Joseph Sparr (above) 
began his career 
working for his uncle's 
drug store in Ne>v York 
City. He opened Sparr's 
Drug Store in Boston in 
1933, and his son Arthur 
(opposite page) joined 
the family business a 
decade later. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



43 




you drop it, you buy it!" With a 
wink, he quickly added an aside: 
"See how I treat my customers?" 



nearly wiped them out. Like his father 
before him, Arthur was still a high school 
student when, in 1943, he joined the fam- 
ily business. "With the war going on," he 
recalls, "there was a labor shortage in the 
country. My father needed the help, so he 
turned to me." (Arthur's brother, Harold, 
also joined the family business before 
striking out on his own in the 1970s.) 

"I remember how funny it was to see 
our customers coming into the store 
in their army uniforms," Sparr says. 
"They were medical students one day 
and soldiers the next." His father, he 
adds, often brought home for dinner 
some of the young students he befriend- 
ed through the store. Recalls Sparr with 
a laugh, "I got to know some guys who 
went on to famous medical careers when 
they were still wet behind the ears." 

An Instrumental Role 



For hundreds of HMS doctors, both 
famous and obscure, the short trip from 
the Quad to Sparr's to purchase a first set 
of medical instruments was an institu- 
tional rite of passage. Sparr carit count the 
number of occasions o\'er the years, he 
says, that HMS alumni ha\e come up to 
him and exclaimed, "You were just a 
young whippersnapper when you sold me 
my first stethoscope!" 

As if on cue, a recent graduate, en route 
to a cardiology fellowship in New York 
City, seeks Sparr's advice as to whether 
he should upgrade to a stethoscope more 
sophisticated than the Littmann he had 
used while at HMS. 

"Years ago," Sparr confides, "every- 
body bought the same basic diagnostic 
set: ophthalmoscope, otoscope, tuning 
fork, reflex hammer, and, of course, 
stethoscope. Today you have fancier ver 
sions of these same tools but, if you ask 
me, a lot of it isn't necessary — just bells 
and whistles." 




If the tools of the trade haven't evolved 
much over the course of the nearly 60 
years he served the HMS community, 
Sparr says, the t)'pes of students purchas 
ing those tools have changed dramatical- 
ly. The "arrival of the ladies," as he refers 
to the 1945 admission of the first women 
to HMS, stands out in his memory. 
Although the diversity of the students 
has increased greatly, their general char- 
acter has remained steadfast, in Sparr's 
\iew. "Students aren't always the easiest 
people to deal with because they like to 
challenge authority," he says, "but to the 
end I always lo\'ed working with them." 

His affection did not go unrequited. 
For many HMS graduates, the Sparr's 
experience is intrinsically bound up with 
the memory of the passage to the world of 
adulthood as well as of medicine. In the 
delicate recollection of one graduate from 
the 1960s, who prefers to remain anony- 
mous: "Well, how shall I put it? Before 
birth control pills, Sparr's was a key play- 
er in many a Saturday night date; lots of 
male alums have a story about that." 

Yet bragging rights for the most note 
W'Orthy Sparr's transaction may well 
belong to Lloyd "Holly" Smith '47. As a 
fourth-vcar student. Smith was asked to 



work with the late John Merrill '42 to 
make a new artificial kidney operative. 
"We had to start from scratch, includ 
ing formulating the dialvsis fluid," Smith 
recalls. "At that time we had no appropri 
ate pumps for returning cleansed blood to 
the patient, so we had to construct one 
from a refrigerator pump. In addition, no 
non-wettable containers to reduce the 
tendency toward clotting were available 
to couple with the pump. In a moment of 
inspiration, we hit upon the use of con- 
doms. As the junior member of the team, it 
was my task to go each Monday to Sparr's 
to purchase a gross of 144 condoms. Never 
since ha\'e I been held in such awe and 
respect for my presumed amorous powers 
as on those heady occasions!" 

Seeing Sparr's 

Loyal connections forged between the 
Sparrs and HMS alumni tended to per 
.sist for decades after the students gradu 
ated. According to Daniel Federman '53, 
a classmate returned to his nati\e Ger 
many after graduation from HMS. "He 
became an outstanding thoracic sur 
geon," Federman says, "and came back to 
visit during our 25th reunion. When he 



44 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



"■mji 



^ 



A DAY'S WORK: 
'ram left) Arthur Sparr 
ated at the lunch 
unter, staff waiting for 
e lunchtime cro^d, 
.parr searching through 
boxes in his storeroom, 
Sparr helping medical stu- 
dent Kevin King '05. 



walked into Sparr's for the first time in a 
quarter century, the counterman recog 
nized him immediate!)' as 'that guy who 
went back to Germany!'" 

Federman himself also enjoyed the sus 
taining benefits of the Sparr's experience. 
"To sa\'e money when I was a student," he 
says, "I ate at Sparr's many times and near 
ly always had pea soup and nothing else. If 
pea soup in general, and Sparr's version in 
particular, had had any important toxicity, 
I probably wouldn't be around today." 

Besides the otoscopes and EKG 
calipers — not to mention the cheese- 
burgers and frappes served at its lunch 
counter — Sparr's drew HMS alumni into 
its orbit for the fellowship it pro\'ided. 
Says Don Bienfang "64, "Like most of my 
classmates, I think of Sparr's as the place 
where we made the exciting purchase of 
our first tools of medicine — I .stUl have 
the stethoscope I bought there in 1961. 
But the relationship went beyond that. 
Arthur and his Dad knew us all and some 
of us e\'en rented rooms abo\'e the store 
when we moved out of \ anderbilt Hall." 

Michael LaCombe '68 remembers the 
ad\ice and fa\'ors, large and small, that the 
Sparrs dispensed his way: "They told me 
which stethoscope to buy, suggested 
which Boston paper I should begin read- 
ing (the Globe in preference to the Herald). 
sa\'ed the New York Times for me, kept a tab 
when I didn't have any money, told me not 
to study on Saturday nights (too much 
fun stuff going on in Boston) — and old 
Mr. Sparr sternly ad\'ised me that 1 should 
relax and enjoy my four years because 
Har\ard would never flunk me out!" 

"In many ways," adds Stephen Pauker 
"68, "the Sparrs functioned as parents, as 
the greater extended family — and a lo\'c- 
ly family at that — to many, many medical 
students over the years." Pauker's close 
relationship with the Sparrs reaches back 
to his second year at HMS, when he 
worked as their sales rep, showing black 
bags and other medical equipment to his 
classmates and collecting their orders. 



Pauker has purchased many of his own 
office supplies and e\'ery stethoscope he's 
e\'er owned for the past thirty odd years 
of his medical practice from Sparr's. 

Pauker expresses his fondest apprecia 
tion of the Sparrs, however, for the con 
stant, cheerful support they offered him. "I 
used to go by there three or four times a 
week and they were always encouraging, 
whether the talk was about the life of a 
doctor or just life in general," he says. "And 
they were kind and helpful in the way 
you'd expect family to be. When I got 
married at the end of my third year and 
couldn't find an affordable place to hve, 
the Sparrs came to the rescue by renting 
me and my wife — also a medical student 
at the time — our first apartment." 

Over the years, the HMS community 
has expressed its gratitude to Sparr's at 
more than one .Alumni Day celebration at 
which the proprietor has been an hon 
ored guest. HMS students have paid trib 
ute in more creative ways as well. "Most 
of my classmates bought all their medical 
equipment at Sparr's, whose motto was, 
'If we don't ha\'e it, you don't need it!"" 
remembers Thomas Gutheil '67. "In 
recognition of the centrality of the store 
in our beleaguered student li\'es — not 
only for medical supplies but for the odd 
magazine, hasty breakfast, candy bar, 
kind word, and such — in our Second Year 
Show, we immortalized our alma mater as 
Sparr's Medical School, whose motto 
was, 'If we can't cure it, you don't ha\e it!""' 

The show's plot re\'olved around the 
School's \ictory in the medical Olympics. 
The rousing School fight song belted out 
by the show's students featured memo 
rable lyrics; 

Rake those dollars into the till, here's 
to Sparr's victorious still, 

Sparr's is best, forget the rest; Sparr's 
is the greatest with the latest' 

Sparr's has got the whole world h\ 
the epididymis. 

Sparr's, Sparr's, SPARR"S.' 



This song, Gutheil reports, "w ith or 
without tuba accompaniment," is still 
sung at reunions of the Class of 1967. 
"For so many people in our class, 
Sparr's offered students a personal con- 
nection," Gutheil adds. "The sons knew 
many of us by name, and we used to 
tease them by Bostonizing their names; 
'Hey, Aaathuh, how aayah?" Many of us 
are quite saddened by the end of such a 
valued institution." 

All Good Things 

Arthur Sparr, too, will miss the many 
graduates who w^ent on to set up prac- 
tice locally and stayed in touch with 
him o\er the years. Given the low profit 
margin created by selling just above 
cost, as Sparr did for many years, his 
operation has no heir apparent. For the 
time being, though, fans of the gastro- 
nomic fare available for so many years at 
the Sparr's lunch counter may coasole 
themselves with the offerings of Sparrif- 
ic, a full-service restaurant whose menu 
features many classic items from the 
Sparr's of old — omelettes, burgers, and 
grilled cheese sandwiches — served up 
in the same space that the fabled drug 
store recently occupied. But the School, 
which purchased the buUding for an 
undisclosed .sum, eventually plans to 
construct new facilities on that site, to 
fulfill its space-starved needs. 

.Although its physical structure may 
be destined for demolition, the legacy of 
Sparr's Drug Store will endure in HMS 
lore. A wrecking ball cannot vanquish 
the rare camaraderie that flourished 
among his customers for nearly seven 
decades, Sparr says; "You"d have a Nobel 
Prize winner sitting on a stool at the 
lunch counter next to a guy who had 
just gotten out of the slammer. How- 
many places are there like that?" ■ 

Beverly Ballaro is associate editor of the 
Harvard Medical Alumni Bulletin. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



{THE RELUCTANT} 





^ 

■ 



A Boston blue blood with dreams of trading his stethoscope for a farmer's 
plow finds he can't turn his back on a community in need 

MANYBERRiES IN JULY 1948 WAS HOT AS HELLFIRE. 

I had just broken the axle of my entomology survey truck in the 
sand hills south of this rural hamlet in Alberta, Canada. The 
town owed its name to the Blackfoot, who had dubbed the near- 
by creek Akoniskway ("many berries") because of the trove of 
chokecherries and saskatoons that grew there. The charm of the 
native legend was far from my mind on that sweltering summer 
day, however. After hitching a ride into town to arrange 
for towing, I joined my survey crew in the local beer parlor. It 
didrft look like our truck was going to get fixed any time soon. 



by Sterling Haynes 



46 HARVARD MEDICAL ALUMNI BULLETIN 




MANYBERRIES=- 



*-^ 





4fr-- 



RITES OF PASSAGE: 
Friends in the Orion 
area gathered with Doc 
Bartlett for his birthday 
in 1938 (left). The train 
stop at Man/berries, 
the hamlet Doc called 
home after leaving 
•'^* Boston behind (above). 







the first meeting, he kept talking about 
the community knew what that meant, 



' 

1 



Our meeting place was in the bar of the 
only hotel in town. The slovenly keeper 
wore a sweatshirt that proclaimed, 
"Manyberries isn't the end of the world, 
but you can see it from here." Tacked onto 
the wall behind the bar was a flyspecked 
portrait of King George VI and a Union 
Jack. A stuffed albino pheasant perched 
on a shelf above the flag. 

It would be 47 years before I again set 
foot in Manyberries, this time to study 
the life of Dr. Samuel Bartlett. By then, I 
had a lifetime of general medicine prac- 
tice to guide me — and give me a keen 
appreciation of what a godsend Doc must 
have been to his adopted community. 



Wand 



ering 



Brah 



mm 



48 

J 



Samuel Bartlett was born in Boston in 
1875. When he graduated from Harvard 
Medical School in 1899, he promptly 
joined his father's medical practice in 
Boston. To make himself appear older, 
the young physician grew a beard. 

His father, George Pinksham Bartlett, 
had also attended Harvard Medical 
School, from 1869 to 1871, although he 
never actually graduated. George Bartlett 
had been something of a prodigy, earning 
his bachelor's degree from Tufts Universi- 
ty at the tender age of 14 before taking up 
the study of both dentistry and medicine 
at Harvard. Acquaintances described him 
as "a man of genial nature, wide informa- 
tion, and most agreeable manners, and a 
surgeon held in high rank." 

Sadly, George Bartlett died suddenly 
of meningitis less than a year after his 
son's graduation from medical school. 
Perhaps it was his father's death that 
caused the younger Bartlett to give up his 
medical career at his father's Boston san- 
itarium and venture to southern Alberta 
to seek a much different hfc. 

According to those who knew Doc, 
the only glimpse into his past that he 
ever revealed to the Manyberries folks 
involved the story of how he came to be 
partially blind. While playing hockey as 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 




NINE LIVES: Doc Barlett's devotion to cats was legendary (top left). Before settling 
in Alberta, Doc spent some time laboring on various construction sites in Fort 
Steele, British Columbia (top right). When not tending to his patients. Doc tended 
to the 60-odd pigs and horses he kept on his Manyberries farm (above). 



the 'ex-officio' members 'having a say.' No one in 
but the Doc soon learned 'em." 





a youth, he had sustained an injury that 
cost him the sight in one eye. Although 
various rumors circulated over the years, 
he never discussed with the members of 
his adopted community the impetus 
behind his journey from the urban, intel- 
lectual climate of Boston to the rough 
prairie frontiers of Canada. 

"The Last, Best West" 

When Doc landed in the new province of 
Alberta, he joined an exodus of settlers 
who had been streaming steadily into the 
Canadian West .since the turn of the 
nineteenth century. Spurred by the com- 
plerion of the Canadian Pacific Railway, 
between 1895 and 1914, more than a mil- 
hon settlers made their new homes in 
what was once described as "the last, 
best West." To entice settlers to the vast. 



underpopulated expanses of the West 
ern prairie territories, the Canadian gov 
ernment offered inexpensive, plentiful 
land and an environment of social and 
religious freedom. Many of the settlers 
emigrated from the United States; by 
1915, approximately 82,000 Americans 
had settled in the province, making up 
nearly a fifth of the total population. 

Once he joined the legions seeking a 
new life north of the border. Doc seemed 
to have abandoned not just his Boston 
roots but his medical career as well. Per- 
haps ine\itably, though, gi\'en the haz- 
ardous quality of life in that time and 
place, his old caUing crossed paths with 
his adopted one; while working as a tran 
sient har\'est laborer on a threshing crew 
in Manitoba, Doc successfully treated a 
fellow worker \\'ho had broken his leg. He 
subsequently wandered to Fort Steele, 



British Columbia, where he put his Har- 
vard-trained physician hands to work in 
various construction jobs and then to the 
Lethbridge district of .Alberta, where he 
toiled on the Northern Irrigation Project. 

It was the lure of new land that finally 
attracted Doc to settle down in the 
Glassford district south of a place that 
came to be called Orion. Today, Orion is 
one of many ghost towns dotting Alber- 
ta. Although the tiny hamlet still boasts 
seven or so hardy souls in residence, they 
hve on streets lined with empty homes 
and abandoned buildings. 

When Doc set up his homestead on 
the bank of Manyberries Creek, in the 
winter of 1911, though, Orion was still in 
its infancy. With dreams of becoming a 
farmer, the doctor pre-empted a half 
section on the creek and carved a 
dugout shack into its bank. This under- 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



49 




walked the Black and White trail to 
to obtain a supply of sulfa for four 




50 



ground earthen hut, friends reported, 
was always a mess. Living alongside Doc 
and his collection of medical books 
were pigs; his pet boar, known affec 
tionately as Jojo; cats; and horses. 

Yet the doctor's crude and remote 
dwelling also harbored an oasis of ci\T- 
lization within; according to his nearest 
neighbor, Barney Gogolinski, the doctor 
always kept up with his medical journals 
and popular magazines, including the 
Saturday Evening Post and the Atlantic 
Monthly. And he corresponded regularly 
with his sister, Madeline. But no one in 
Manyberries remembers him ever travel 
ing East or receiving visits from Massa 
chusetts friends, family, or classmates. 

The one connection Doc did maintain 
to his past was a distinct Boston accent. 
This he combined with a large vocabu- 
lary, much in evidence during his offici- 
ating at local town meetings. Barney 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 



Gogolinski recalled how "the Doc" 
always abided by Robert's Rules: "At the 
first meeting, he kept talking about the 
'ex-officio' members 'having a say.' No 
one in the community knew what that 
meant, but the Doc soon learned 'em." 

Country Doctor 

As reported by his patients, the doctor 
was meticulous, taking great care to ster- 
ilize his primitive instruments. He did 
midwifery and minor surgery and gained 
renowTi for the fussiness of his reduction 
of fractures, which he immobilized using 
narrow slats of applebox wood tied 
together. He also pulled teeth. 

During the worldwide flu epidemic of 
1918 to 1919, Doc toiled ceaselessly and 
dispensed quinine with a lavish hand. He 
was ably assisted in his efforts by nurses 
and volunteers, and the deaths were 



remarkably few. He e\'en consented to be 
licensed as a medical health officer with 
a special permit to practice medicine, a 
license he never bothered to renew. 

After the epidemic. Doc declined offers 
to practice at the Medical Arts Clinic in 
nearby Medicine Hat, an important busi 
ness center that had sprung up when the 
Canadian Pacific Railway made its way 
west. Instead, he w'as content to garden, 
growing watermelon by the wagonload, 
and care for the li\cstock and his inany 
cats back in his Manyberries shack. 

It took a tragedy to compel Doc to 
abandon his beloved dugout. Some 
neighbors inhabiting a similar struc- 
ture died of carbon monoxide poison- 
ing when a freak snowstorm covered 
their chimney and door. It was soon 
after that Doc settled in the town of 
Orion. This meant losing his home- 
stead, but the people of the district 



Medicine Hat, a distance of 50 miles, 
town children who had scarlet fever. 



built the doctor a small house. With 
this house, his magazines, and his unof 
ficial medical practice, he appeared to 
be a contented bachelor. 

Odd Man About 



The folks of Manyberrics and Orion toh 
erated the doctor's eccentricities. As the 
unofficial physician serving a widely 
scattered communit)' of pioneers, most 
of whom li\ed dozens of miles away from 
the nearest hospital. Doc earned the 
trust and gratitude of his patients, with 
few questions asked about why he had 
given up his medical practice in Boston. 

Doc was said to ha\'e had a shifty look 
because of the peculiar squint in his 
injured eye. The children were fright- 
ened of his bad eye, ragged beard, bib 
overalls, and serious demeanor, but the 
adults considered him an honest man. 

It was common lore that Doc lo\ed to 
chew "snooze." Since his patients knew 
of his passion, he never had to buy any. 
With a large pinch — three fingers and a 
thumb — he could empty a box. His vora 
cious appetite for food was surpassed 
only by his olfactory senses. It was 
rumored that he could smell bread bak- 
ing a mile away. After a large meal, he was 
not above criticizing the cook's efforts, 
albeit in a good-natured fashion. 

Doc was a frequent presence at many 
dinner tables, since he rarely accepted 
money for his medical ser\'ices. He was 
paid in kind: bread, beef, beer. One old- 
timer remembers a dinner that Doc was 
supposed to eat with a group of men. 
During an argument over a card game, 
which distracted the other guests. Doc 
single handedly consumed the entire 
meal of cabbage and sausage casserole. 

In the early 1930s, the Manyberrics 
Chinook reported that Doc had been 
rushed to Medicine Hat to undergo 
emergency surgery for a strangulated 
hernia. During his convalescence, he 
impressed the doctors and nurses on 
staff with his medical knowledge and 



kindly personality. The Christmas fol 
lo\\ing this episode, the nurses received 
turkeys, compliments of the doctor. 

His hospital stay also signaled a per- 
manent change in Doc's garb, one most 
likely recommended by the physician 
in the Medical Arts Clinic. When he 
returned to Orion, Doc was suitablv 




FIRESTORiy\ AND CONTROVERSY: A grain 
elevator in Orion, where Doc Bartlett 
nearly died in a 1953 house fire (facing 
page). Despite his eccentricities. Doc 
forged enduring friendships, including 
one with Sidney Dann, pictured above, 
with vs^hom he liked to argue politics. 



dressed in a shirt, tie, jacket, and trousers. 
He was not, however, suitably washed. 

Doc's failure to bathe and his fondness 
for snooze made him a somewhat pun- 
gent dance partner. But despite his odor 
and difficulty in finding partners, he con- 
tinued to show up at community dances, 
where he moved with considerable vigor. 



A Fever Pitch 

In 1936, at the instigation of the public 
health doctor and a local widow whose 
husband had died of Rocky Mountain 
spotted fever. Doc began to work on 
developing a vaccine for spotted fever. 



but ended up using a crude vaccine 



sup- 



plied by the provincial go\'ernment of 
Alberta instead. Concocted from infect- 
ed ticks attenuated with phenol, the \'ac- 
cine resulted in many local and systemic 
reactions. Aided by the public health 
nurse. Doc established spcitted fever clin- 
ics, where he was assisted by townspeo- 
ple, nurses, and go\'ernment doctors. 

Doc also provided inoculations for 
diphtheria and smallpox. And when 
scarlet fever epidemics raged in the dis- 
trict between 1937 and 1942, Doc once 
walked the Black and White trail to 
Medicine Hat, a distance of 50 nulcs, to 
obtain a supply of sulfa for four tov\'n 
children who were ill. Braving the 
prairie winds, dust, and dramatic tem- 
perature fluctuations must have been 
arduous for a man in his sixties. 

In 1953, Doc's Orion home caught fire. 
He was taken to Medicine Hat suffering 
from severe burns and shock. After a 
slow recovery, he spent winters in "the 
Hat" and summers in a newly built 
Orion house, where he v\'orked in his 
garden. The Farm Women's Institute — a 
group of politically and socially minded 
women — provided him with care. 
Apparently Doc, having lost everything 
he owned and very nearly his life in the 
fire, was their baby. 

Doc died on November 10, 1956, at the 
age of 82. The Medical Association of 
Medicine Hat had a granite field boulder 
brought into the HUlside Cemetery as a 
marker. This stone stiU marks the grave 
of one of Alberta's most eccentric and 
caring physicians. ■ 

Sterling Hayncs, MD, is a retired general practi- 
tioner from British Columbia, where he provided 
medical care to people in rural areas for decades. 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



51 



ATJIMNTIS PROFIT. K 



ARTHUR GUYTON '43A 



The Grand Daddy of Them All 




RTHUR GUYTON '43A ONCE 

looked forward to a career 
as a cardiac surgeon. His 
medical training at HMS 
had been accelerated because of the 
shortage of physicians during World 
War II. During the war, he performed 
surgery at Bethesda Naval Hospital and 
conducted research on bacterial war- 
fare at Camp Detrick in Maryland. 
When the war ended and he 
was discharged from the Navy, 
he moved back to Boston, eager 
to begin his life as a surgeon. 

But in late 1946, Guyton was 
stricken with a severe case of 
polio. He was sent for intensive 
rehabihtation to Warm Springs, 
Georgia, where he remained 
for seven months. Although he 
reco\'ered and regained some of 
his strength and mobility, his 
right leg, left upper arm, and 
both shoulders remained para- 
lyzed. His dream of a surgical 
career was over. 

E\'cn while in rehab, howev- 
er, Guyton turned his atten- 
tion toward other challenges. 
He designed a walking brace, a 
special hoist for polio patients, 
and a motorized wheelchair 
controlled by an electric joy- 
stick to help patients maneuver 
more easily. This inventiveness 
was simply an extension of 
a childhood passion he had 
indulged in his youth in 
Oxford, Mississippi. 

"I've always loved to build 
things," Guyton says. "As a young man 1 
made a lake, then tiny wooden boats to 
float on it. A great Christmas present for 
me was a bag of cement, which I could 
use to build roads." 

Guyton passed on his love of building 
things and mastering new skills to his 
eight sons and two daughters. He taught 
them woodworking, electronics, and 
masonry, and they worked on projects in 



a machine shop behind the hou.se. With 
his guidance, the children learned to 
build everything from go-carts and ham 
radios to a swimming pool and a tennis 
court for their home. 

"For science fairs, the children would 
work in the shop, using the lathe, rrdll, or 
welding equipment to make toys, engines, 
and other devices," Guyton recalls. "We 
also talked a great deal about physics 




♦ 



1 



i 1 



CHIPS OFF THE OLD DOC: All ten of Arthur Guyton's chil 
dren followed their father's career choice of medicine. 



and chemistry, and ho\\- these were the 
bases of engines, motors, and electronics." 

One subject they rarely discussed 
was medicine. And yet, Guyton's chil 
dren — all ten of them — followed their 
father's career path and became physi 
cians. All eight sons attended HMS. 

The remarkable achievements of the 
Guyton family have generated substan 
tial media co\'erage. But Guyton says he 



didn't find it at all unusual when his chil- 
dren decided, one after another, to pur- 
sue careers in medicine. Education was 
highly \'alued in the Guyton household; 
Arthur credits his wife, Ruth, with 
instilling a love of learning in the ctul 
dren b\' reading to them c\ery night. 

Yet to help explain why all of his chil 

dren became doctors, Guyton suggests, 

"One reason may be that because I had 

poho, I was a patient of theirs 

from the beginning. When my 

' oldest son, Da\id, was about 

fi\'e, his mom would say, 'Go 

and push your daddy in here.' 

The children were always there 

4P - to help. They had a patient of 

their own, which gave them 

»more of an introduction to 
medicine than anything I could 
have taught them." 

David Guyton '69. a profes 
sor of pediatric ophthalmology 
at Johns Hopkins, denies ever 
J perceiving his father as a 
IP •• patient. "We never thought of 
at .^ him as handicapped," he says. 
HI "He was bright and energetic, 
"~ and he seemed to kno\\" every 
thing about everything." 

Da\'id recalls his father offer 
ing guidance to the children on 
a variety of projects. In fact, the 
Guy tons built their home in 
Jackson, Mississippi, based on 
Arthur's design. "It was the best 
thing for us to have his brain 
guiding our hands," David says. 
"We kids e\-en redid much of 
our house with ni)' father talk 
ing us through it. I \':ilue that training." 

Arthur Guyton's own father, Billy 
Guyton, \\-as dean emeritus of the med 
ical school at the University of Mississip 
pi in Oxford. "When I was young, I some 
times worked around my father's office," 
Arthur recalls. "I watched him work, and 
tried to learn a little bit of medicine." 
Arthur's older brother, the late Jack Guy 
ton '37, was also an influence. When 



52 



HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 




IT TAKES TWO: Guyton ascribes much of 
his family's success to the warmth and 
intelligence of his wife, Ruth, >vho macJe 
it a point to read to the children nightly. 

Arthur visited his brother at HMS, he 
became interested in Jack's work. 

Guytorfs own professional path led 
him to become a world-renowned 
researcher and teacher. He accepted a 
teaching position in the Department of 
Pharmacology at the University of Mis 
sissippi's School of Medicine, and later 
the chairmanship of the Department of 
Physiology. Guyton taught 
there until his retirement in 
1989. Despite his initial incli 
nation toward surgery, the 
academic life suited him. 

"I was fascinated by physi 
ology," he says. "But I hadn't 
realized how much fun it 
would be to teach it. I was 
almost the same age as the 
students, so we could talk 
back and forth easily. It was a 
wonderful environment." 

Guyton also loved to tack 
le new research topics, and 
some of his best- known work 
in cardiovascular physiology 
challenged long-held beliefs. 
His research showed, for 
example, that cardiac output 
is controlled by peripheral 
tissues — not the heart, as was 
the wisdom of the time. Guy- 
ton's research also pinpointed 
the critical role of the kidneys 
m controlling blood pressure. 
These discoveries earned him 
numerous awards, including 
the Research Achievement 
Award given by the American 
Heart Association. 

As for the Guyton grand 
children, David says that many 
of them have learned from 



their physician parents the challenges 
doctors face today, and none has chosen 
to pursue medicine thus far. "They see 
how hard we're working," Da\id says. "In 
a way, our father tricked us all into pur- 
suing medicine. We saw him having a 
\'ery nice life, home by six, interacting 
with his family, writing his textbook at 
night. Dad was comtortable, happy, and 
commanded respect. Medicine was a 
natural career for us to pursue." 

Arthur Guyton is sorry to see the 
demands today's medicine places on 
his children. But as a retired physician, 
he remains passionate about the pro- 
fession. He is currentlv at work on the 



eleventh edition of his Textbook oj Med- 
ical Physiology, first published in 1956 
and since translated into many lan- 
guages, including Turkish, Indonesian, 
and Serbo-Croatian. "It's a full time 
job trying to keep the book from get- 
ting too long," he says. 

Guyton's love of learning how things 
work — from the physiological process- 
es of the body to the mechanical aspects 
of a boat, wheelchair, or car — and his 
desire to share that knowledge have 
remained constant throughout his life. ■ 

Susan Cassidy is assistant editor of the 
Harvard Medical Alumni Bulletin. 



Is There a Doctor in the House? 



Thomas Guyton '87, 
anesthesiologist, Memphis 



David Guy ton '69, pediatric 
ophthalmologist, Baltimore 



James Guyton '85, orthopedic 
surgeon, Memphis 



Douglas Guyton '81, 
anesthesiologist, Reno 



Jean Gispen, MD, 

rheumatologist, Oxford, 

Mississippi 




6 



Robert Guyton '71, 
cardiothoracic surgeon, Atlanta 



John Guyton 73, internist. 
Chapel Hill 



Catherine Greenberger, MD, 

former internist, Boston 



Arthur Guyton '43A. physiology 
professor, Oxford, Mississippi 



H^ 



Steven Guyton '75, 
cardiothoracic surgeon, Seattle 



% 



Gregory Guyton '93, orthopedic 
surgeon, Baltimore 

Jack Guyton '37 (Arthur's late brother), 
ophthalmologist, Detroit 




Billy Guyton, MD (Arthur's late father), 
medical dean, Oxford, Mississippi 



WINTER 2003 • HARVARD MEDICAL ALUMNI BULLETIN 



53 



CT.ASS NOTES 



NEWS ABOUT ALUMNI 



Max Kurzer 



1936 "I teach bridge at a retirement 
home tA\o days a week. Also, I 
am writing two books." 

George W. r.nmsrork 

1 94 1 "I am still working, though 
with sUghtly reduced hours. 
I am helping with several 
courses at the Johns Hopkins 
Bloomberg School of Pubhc 
Health and continuing 
research on cancer and tuber- 
culosis in my main office in 
Hagerstown, Mar)'land. My 
avocation is still mainly music 
(Washington Count)- Muse- 
um Recorder Consort; second 
bassoon in Frederick Orches- 
tra), but hearing loss is 
threatening both my teaching 
and music." 

Wiley F. Barker 



1 944 "I am still ah\e and \\Titing, if 
not kicking so welL one book 
on the histor)' of the Societ)' 
of Clinical Surger)' for its 
100th anni\ersary in 2002; an 
e-book on how to take care 
of those orchid plants you see 
in the grocer)' store; and a 
write-up of the characters in 
the Barker family (those of 
years past). I am stiU enjo)'ing 
our rustic 'ranch.' I am active 
as a consultant to the Califor- 
nia Board of Medicine and 
to the Board of Ad\isors for 
UCLA Medical Center, and I 
make occasional \isits to the 
Peripheral Vascular Service 
at UCLA." 

Eugene B. Brody 

was part of a multinational 
mission to Uzbekistan in 
autumn 2002, under the aus- 
pices of several international 
and Uzbek nongovernmental 
organizations. The group pre- 
sented seminars and held 
informal meetings with 



women leaders and local 
agencies in Tashkent, 
Samarkand, and Bukhara, 
focusing on women's rights 
and responsible parenthood 
in Uzbekistan. Brody retired 
as secretar)' general of the 
World Federation for Mental 
Health in 1997 and now 
serx'es as the organization's 
senior consultant, as well as 
co-chair of its Committee on 
Responsible Parenthood. 

John W'. Braasch 



1 946 "I've finally retired, ha\ing 
put it off for a number of 
years by starting and running 
a surgical residency at Lahey 
Clinic and then working in 
our cell biolog)' lab (low-level 
appointment; no Nobel 
Prize). I am now trying to 
play termis and duplicate 
bridge. Keeping up with my 
grandchildren is also a full- 
time job." 

William R. Owen 

1 949 "I play tennis or golf daily. I 
maintain an office and a sec- 



retar)-, and help defend med- 
ical malpractice and personal 
injur)' (cardiac-related) hriga- 
tion. Margaret, our t^vo 
daughters, and our five grand- 
children are welL I'm looking 
forward to our 55th in 2004." 

Ralston R . Hannasjr 



1950 'I am the new owner of 

Montgomer)''s Irish Pub in 
Tuscon, a great neighborhood 
restaurant and bar. Come see 
me when you are in Tucson." 

Daniel T. Young 
"I have been retired from the 
Universit)' of North Carolina 
School of Medicine facult)' for 
ten years, but remain in 
Chapel Hill. We are working 
here to get laws passed to 
make adequate health care a 
right in North Carolina and 
to require the North Carolina 
legislature to figure out how 
to do it." 

Charles Bauer 



1953 "It was wonderful seeing Bill 
Temby on his recent \1sit to 




HARVARD MEDICAL ALUMNI BULLETIN • WINTER 2003 










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